To those members, Ryan’s most important message came at the end, and it boiled down to just a couple of sentences that have nothing to do with health-care policy. “This is the closest we will ever get to repealing and replacing Obamacare,” Ryan said. “It really comes down to a binary choice.”
It’s now or never, and it’s this or nothing.
Over the last 48 hours, the question swirling over the White House and the Capitol was whether President Trump and the Republican leadership would accede to conservative requests to significantly rewrite the bill Ryan and his committee chairmen released on Monday. Everyone seemed to get a different answer. Conservative lawmakers and advocates left separate meetings with Vice President Mike Pence at the Capitol and Trump at the White House believing the administration was open to changes and negotiation. About an hour before Ryan spoke, the Republican Study Committee—the large bloc of conservatives in the House—endorsed two significant amendments that would freeze enrollment in Obamacare’s Medicaid expansion and institute work requirements for the program. Members of the smaller but more confrontational House Freedom Caucus want to axe the proposal’s refundable tax credits, which they call a new entitlement program.
Ryan, however, made clear that these ideas wouldn’t fly. Asked by a reporter whether his argument meant that the bill would have to pass without significant changes, he replied: “Correct.” The speaker explained that Republicans were limited by the Senate’s strict budget reconciliation rules requiring that any changes to current law involve taxes and spending, not policy changes. They need to use reconciliation to pass the bill with a simple majority and skirt a Democratic filibuster. Moreover, the speaker knows, but didn’t say, that if conservatives succeed in pushing the bill much further to the right, the leadership could lose the support of moderates, especially those who hold much greater sway in the Senate.
Ryan preached patience by saying the current bill is just one part of a three-step process. The Trump administration, he explained, will also reform health care using administrative powers granted in the Affordable Care Act. And then ultimately, Republicans will finish the job with legislation that is subject to the Senate filibuster, and thus, crucially, will require Democratic support.
Demonstrating the leadership’s commitment to the current bill, two House committees met through the night—more than 50 hours in total—and advanced the legislation without adopting a single substantive amendment. Trump has put on a full-court press at the White House, inviting leading conservative critics for a meeting Wednesday night, dining with Senator Ted Cruz in the evening, and lunching with more conservative House members on Thursday. Another group is going to the White House for a bowling night next week, and Trump reportedly is considering a visit to Kentucky, home of the Senate’s most vocal opponent of the House bill, Rand Paul.