It's Do-or-Die for Repeal-and-Replace

The long-awaited Republican alternative to Obamacare is due out this week, but the scramble for votes has already begun.

Jim Lo Scalzo / Reuters / Pool

“We’ll go through the gate,” the speaker of the House vowed. “If the gate is closed, we’ll go over the fence. If the fence is too high, we’ll pole vault in. If that doesn’t work, we’ll parachute in. But we’re going to get health-care reform passed for the American people.”

The speaker of that quote was not Paul Ryan but Nancy Pelosi, just over seven years ago. Don’t be surprised, though, if the current keeper of the gavel utters a similar statement in the weeks ahead. Pelosi made that declaration at a precarious moment back in 2010, in the days after Democrats had lost their filibuster-proof majority in the Senate and the drive to enact the Affordable Care Act appeared on the verge of collapse.

Ryan is approaching a similar inflection point in his years-long effort to erase the law Pelosi succeeded in enacting. The legislation his committee chairmen have drafted remains officially under seal, but it has been beset on seemingly all sides by criticism. Democrats are waiting with arrows drawn to attack it. Rank-and-file Republicans, while supportive in general, are anxiously awaiting the details and worried about how to sell the plan’s less generous components to their constituents. The party’s more centrist members say they won’t rip up the law’s expansion of Medicaid—a demand that makes true repeal all but impossible. And most concerning for the speaker, the conservatives who in the past have been more willing to buck the leadership remain unconvinced that the Ryan-backed bill won’t simply replace Obamacare with, in the words of Representative Dave Brat of Virginia, “another giant federal program.”

“If the replacement plan is Obamacare Lite, it’s not going to pass,” warned Representative Raúl Labrador, a member of the hardline House Freedom Caucus. The conservative group has raised concerns about a cornerstone of the emerging plan: the use of refundable tax credits to subsidize the purchase of health insurance for people who don’t get coverage through their employer. The policy, critics on the right say, is too similar to the tax subsidies already in the Affordable Care Act.

Even though GOP leaders have yet to release their bill, the sales pitch is already well under way. Across the Capitol last week, senior Republicans scurried from meeting to meeting, briefing lawmakers on the evolving proposal while soliciting feedback on how to improve it. Inside a meeting of the House GOP conference on Thursday, Ryan brought renewed intensity, and a sense of urgency, to his push, lawmakers said. The speaker told Republicans he wanted the House to pass its Obamacare repeal-and-replace bill within three weeks. First, however, it must advance through four separate committees before a floor vote. Both the Energy and Commerce and Ways and Means panels hope to mark the bill up this week. It would then go to the Budget Committee and finally to the Rules Committee.

Meeting that deadline would give the Senate time to debate and vote on the health bill before Congress goes on a two-week break for Easter next month. Another key, if unstated, reason for the crunch: Party leaders want both the House and Senate to pass the legislation without an extended recess interrupting their work—during which their members would have to endure another round of town halls filled with supporters of Obamacare that could sap momentum for the bill.

In the House GOP meeting, Ryan made clear what President Trump had not during his speech on Tuesday night—that the president was fully behind the leadership’s plan. Moreover, a person in the room said, the speaker relayed another message from Trump to conservative lawmakers who want the House to first vote on a straight repeal measure before moving on to a replacement: The president, Ryan told them, was opposed to “repeal only.” Leadership allies rose to urge members to stick with the team, telling them that they’d take heat from constituents in their districts if they failed to deliver on their repeal-and-replace promise. They’ve enlisted Tom Price, the new health secretary and a conservative stalwart, to lean on his friends to back the legislation that is based on a bill he wrote when he served in the House. And on Friday, Vice President Mike Pence traveled to Ryan’s district in Janesville, Wisconsin, as a show of White House unity with the House speaker.

Yet in both the House and Senate, the private sessions were inconclusive, suggesting that Ryan’s timeline for action may be too aggressive. One hold-up is that the Congressional Budget Office has yet to finish its projections on how much the bill would cost and what impact it would have on the number of people with health insurance. The speaker has argued that the plan’s combination of tax credits, expanded health-savings accounts, and high-risk pools to cover people with pre-existing conditions is broadly similar to proposals conservatives have supported in the past. But the resistance Ryan and his chairmen are facing underscores how little time rank-and-file Republicans have spent grappling with the important details of health-care policy until this year.

Senate Republicans rushed past reporters as they left a Wednesday-evening briefing with House committee chairmen. The meeting, they said, was “positive” and “constructive”—Capitol Hill code for “There is no deal yet.” “It was an interesting discussion” was about all the usually voluble Senator Ted Cruz would say. He added, cryptically, that he thought the talks would continue “for some time.” By Thursday, the Texas conservative had written an op-ed in Politico calling on Republicans to go much further than Ryan’s plan calls for. He wrote that the party should, if needed, overrule the Senate parliamentarian to fully repeal Obamacare’s insurance regulations and mandates. However, the GOP may not be able to do that under the budget reconciliation process, which it is using to roll back the law with a simple majority instead of a filibuster-proof 60 votes.

In the House, Ryan’s biggest problem remains the Freedom Caucus, which, if its three dozen or so members voted as a bloc, could sink the leadership plan. The conservatives’ biggest problem with the bill is its reliance on refundable tax credits, but they’ve also complained about plans to limit the popular tax deduction for health insurance and the lack of a full elimination of Obamacare’s Medicaid expansion. The group’s leaders are aware that Ryan and his team may try to call their bluff, betting that conservatives won’t actually be willing to vote against a repeal bill if it comes up for a vote. The leadership can afford to lose no more than 19 votes to achieve a majority of 218, although the threshold may be slightly lower due to vacancies in the chamber. “I think there would be lots of people afraid to vote no, but I think there would be enough [unafraid] where you couldn’t get to 218,” said Representative Mark Meadows of North Carolina, the Freedom Caucus chairman. Adding to Ryan’s headache, the Koch Industries-backed Americans for Prosperity on Sunday urged Republicans to “go back to the drawing board” after Politico reported that a recent draft contained few changes from the leaked bill that conservatives are opposing.

In addition to conservatives, House leaders must persuade more moderate Republicans to accept a Medicaid compromise that may result in reduced funding—and coverage—in states that expanded the program under Obamacare. “It’s going to be tough,” said Representative Peter King of New York, where, he noted, 800,000 people were newly covered. “We have to get something done, but I have real strong feelings on Medicaid expansion. I didn’t like the concept from the start, but it’s there.”

For all of the GOP’s problems in the House, however, it’s still the Senate that remains the party’s bigger challenge. Senator Rand Paul’s farcical scavenger hunt for the “secret” bill on Thursday and Friday obscured a more worrisome point for party leaders. They cannot count on the votes of Senators Susan Collins of Maine or Lisa Murkowski of Alaska, who opposed a repeal bill in 2015 over its defunding of Planned Parenthood, which is also targeted in the current draft. “There is not a consensus at this point,” Collins said Sunday on Face the Nation. With Republicans holding only 51 votes, Paul’s additional opposition would torpedo the legislation. Cruz and Senator Mike Lee of Utah, who have aligned themselves with the House Freedom Caucus in the past, could be similarly crucial. And other senators, including Lindsey Graham, have warned party leaders against trying to jam them with a take-it-or-leave-it plan that they can’t amend. “I’ll leave it,” Graham warned at a town-hall event on Saturday. The tight margin is one reason Senate Majority Leader Mitch McConnell has been sounding less confident than Ryan about the chances for success in his chamber.

The House speaker remains unbowed. Ryan has not adopted the by-any-means-necessary rhetoric of Pelosi, but he’s crept a bit closer. “I am perfectly confident that when it’s all said and done, we’re going to unify,” he told reporters on Thursday, “because we all, every Republican, ran on repealing and replacing [Obamacare] and we’re going to keep our promises.” The next weeks may well determine if he’s right.