Congressional Republicans spent months fighting among themselves over how to repeal and replace the Affordable Care Act. In the wake of last week’s Senate failure, however, GOP lawmakers find themselves increasingly at odds with President Trump.
The president wants to “let Obamacare implode” in the hopes of forcing Democrats to the negotiating table. Republicans on Capitol Hill plainly don’t. But as Trump contemplates making his most direct administrative assault on the law to date, it’s not clear that his own party can stop him.
The president is expected to decide this week whether to continue paying out subsidies to insurers known as cost-sharing reduction payments. He has threatened to stop them for months, and those threats have picked up in the days since the collapse of repeal legislation in the Senate—even as Republicans have warned that such a move would backfire on the party. “If we were to end up pursuing that course of action, then we as Republicans would end up owning the health-care issue,” Representative Charlie Dent of Pennsylvania told me on Monday. “Further destabilizing and accelerating the collapse of the individual market would be very unhelpful to the people who need health insurance.”
The subsidies are designed to help insurers cover their costs while keeping a lid on copays and deductibles. Industry officials and nonpartisan health-policy experts have warned that halting the subsidies would prompt insurers either to raise premiums or exit the Obamacare exchanges altogether, destabilizing the individual market. Democrats have said it would be tantamount to sabotage, and have pointed out that many of the counties that might lose options or see prices skyrocket went heavily for Trump in November.
“He’s actively trying to make it collapse, taking out his political loss on the American people,” Senate Minority Leader Charles Schumer said Monday. “That’s not being presidential; that’s small, it’s vindictive, and it will hurt millions of Americans he’s sworn to help.”
Republicans haven’t rushed to Trump’s defense, especially when the president has also suggested rescinding a federal rule that would cause members of Congress and thousands of people on their staffs to pay more for their own health insurance.
“I believe that most Republican members of the House don’t want to do anything to accelerate the collapse of the individual insurance market,” Dent said. “I don’t think many Republicans want to see any reckless course of action.”
Indeed, calls for Trump to continue the payments have come not only from critics like Dent, a moderate in the House GOP, but from more senior and more conservative Republican lawmakers as well. Those include the chairman of the House Ways and Means Committee, Kevin Brady of Texas, and the chairman of the Senate Health, Education, Labor, and Pensions Committee, Lamar Alexander of Tennessee. Republicans have also supported the payments legislatively; they were included in Senate Majority Leader Mitch McConnell’s Obamacare replacement plan. While conservative Senator Rand Paul of Kentucky has derided the subsidies as a bailout for insurers, the chairman of the House Freedom Caucus, Representative Mark Meadows of North Carolina, has urged that they continue at least temporarily.
That the cost-sharing payments are now at risk is the result of some sloppy legislating by Democrats when they held congressional majorities in 2009 and 2010. Though Democrats wrote the subsidies into the ACA originally, when Republicans won back the House majority, they alleged in a lawsuit against the Obama administration that the subsidies were illegal because Congress had not expressly appropriated money for them. A federal judge ruled initially in the House’s favor against the payment of the subsidies, but the case was not resolved when Trump took office. The president had to decide whether to continue the Obama administration’s appeal of the ruling, and after discussions with GOP leaders, the administration and the House decided jointly to ask the courts for more time to decide whether they wanted to press the case. It remains in limbo.
The Trump administration has made the payments only on a month-to-month basis, creating uncertainty that insurers have cited in leaving some marketplaces around the country. Yet despite Trump’s claims that Obamacare has already collapsed and is “dead,” insurers have made arrangements to return to several markets next year, plugging some of the coverage gaps that Republicans have highlighted. On Monday, five companies announced plans to sell in Ohio, meaning that 19 of the 20 counties that would have had no insurers in 2018 will now be covered.
Guaranteeing the subsidy payments is at the center of emerging bipartisan health-care proposals to fix Obamacare following the latest collapse of the Republican repeal push. Small groups of senators have discussed legislation that would enshrine them into law, and on Monday, a group of 43 Republicans and Democrats in the House unveiled a proposal that would make them permanent. The bill, championed by a coalition that calls itself the Problem Solvers Caucus, represents a compromise: It offers Democrats the insurer subsidies while giving Republicans the repeal of the ACA’s medical-device tax and a provision substantially rolling back its employer mandate. Unlike most partisan GOP proposals, however, it would not touch Obamacare’s individual insurance mandate. “This proposal I believe can get some traction,” Dent said. “Now whether or not the leadership of both parties will buy into this remains to be seen.”
While the plan elicited a positive statement from House Minority Leader Nancy Pelosi, Speaker Paul Ryan showed little immediate interest. “While the speaker appreciates members coming together to promote ideas, he remains focused on repealing and replacing Obamacare,” said AshLee Strong, a spokeswoman for the Republican.
The White House, too, said it had not given up on the GOP’s fading dream, as senior administration officials reportedly met with Republican senators to discuss a proposal from Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana aimed at bridging the gaps among the party’s 52 members in the upper chamber. But by late in the day, senior Republicans were dousing those hopes again. “There’s just too much animosity and we’re too divided on health care,” Senator Orrin Hatch of Utah, the longest-serving Republican and chairman of the Finance Committee, told Reuters. He surmised that the GOP-led Congress would have to appropriate money to continue the insurer subsidy payments, however reluctantly.
Yet with the House already on recess for the next month, legislation will have to wait. It’ll be Trump’s move first, and by the time Republicans have an opportunity to override him, the damage might already be done—both to the teetering insurance markets, and to his beleaguered party.