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G.O.P. Health Bill Clears 2 House Panels After Marathon Sessions
After Halting Start, Trump Plunges Into Effort to Repeal Health Law
(about 5 hours later)
WASHINGTON — The Republican drive to repeal the Affordable Care Act advanced on Thursday as two House committees approved broad legislation to undo the law and replace it with a more modest system of tax credits and a rollback of President Barack Obama’s Medicaid expansion.
WASHINGTON — President Trump, after a halting start, is now marshaling the full power of his office to win over holdout conservatives and waffling senators to support the House Republicans’ replacement for the Affordable Care Act.
The House Energy and Commerce Committee endorsed the legislation on a party-line vote of 31 to 23 after a session that lasted more than 27 hours. The House Ways and Means Committee had approved the measure in a predawn session on Thursday. The House Budget Committee must give its approval to the measure next week before a final House vote that Speaker Paul D. Ryan plans for the week of March 20.
There are East Room meetings, evening dinners and sumptuous lunches — even a White House bowling soiree. Mr. Trump is deploying the salesman tactics he sharpened over several decades in New York real estate. His pitch: He is fully behind the bill to scotch President Barack Obama’s signature domestic achievement, but he is open to negotiations on the details.
Republicans said they were fulfilling a political promise to uproot a law that had done untold damage.
In so doing, Mr. Trump is plunging personally into his first major legislative fight, getting behind a bill that has been denounced by many health care providers and scorned by his base on the right. If it fails, Mr. Trump will find it difficult not to shoulder some of the blame.
Democrats said the bill would rip health insurance away from millions of Americans and increase costs for many others, and they have the backing of a growing number of senators, health care providers and some conservatives.
“He understands the power he has as president to drive the legislative process,” said Representative Patrick T. McHenry, Republican of North Carolina and a top House vote counter, who was part of a meeting with Mr. Trump in the East Room on Tuesday.
Republicans on both House panels held together and rejected a variety of Democratic amendments while doing little on their own to change the health bill.
“He made it clear that this is his priority, that it has to get done, and he made clear that he has to get it through before he moves on tax reform,” Mr. McHenry added.
Many of the amendments were drafted to make Republicans look heartless or rash, forcing Republicans to cast votes that could be cited in campaign advertisements in next year’s midterm elections.
The bill represents an opening for an administration that has been mired in infighting and controversy over an early executive action on immigration. And it will allow Mr. Trump to make good on a pledge he made in rally after rally in 2016 to replace Mr. Obama’s law, which he called a “disaster.”
“Today marks the beginning of the end of Obamacare,” Representative Steve Scalise of Louisiana, the majority whip, said after the votes on Thursday. “This bill guts Obamacare and starts putting patients back in charge of their health care, without government bureaucrats telling them what they can or cannot buy.”
And it has momentum. On Thursday, two key House committees approved the legislation, which would undo the Affordable Care Act and replace it with a more modest system of tax credits and a rollback of Mr. Obama’s Medicaid expansion. Party-line votes by the House Energy and Commerce and Ways and Means Committees sent the measure to the House Budget Committee for consideration next week before a final House vote that Speaker Paul D. Ryan plans for later this month.
Representative Greg Walden, Republican of Oregon and chairman of the Energy and Commerce Committee, said the bill represented the biggest change in federal entitlement programs since the creation of Medicaid in 1965.
“Today marks the beginning of the end of Obamacare,” Representative Steve Scalise of Louisiana, the majority whip, declared after the votes.
The bill would replace Medicaid’s open-ended entitlement with a per-beneficiary allotment of federal money for low-income people. It would also cut federal payments to states for the expansion of Medicaid — a change that has caused deep concern among governors of both parties and Republican senators from states that expanded Medicaid, like Ohio, Colorado and West Virginia.
The risks for Mr. Trump are high. His initial foray into the debate was a declaration that nobody should lose insurance coverage with a replacement bill — a standard that is likely to be impossible to meet. When House Republicans finally unveiled the legislation Monday night, he declared on Twitter, “Our wonderful new Healthcare Bill is now out for review and negotiation” — hardly a hard line.
Representative Kathy Castor, Democrat of Florida, said: “This is the most radical rewrite to Medicaid that we have seen in decades. The bill will rip coverage away from many of our neighbors.”
Already, debate on the measure is taking far longer than Mr. Trump had hoped, delaying his push to cut taxes, rewrite the tax code and secure a sizable new infrastructure program. If his health care push fails, the reverberations will affect those other measures.
Moments before the bill emerged from the Energy and Commerce Committee, Representative Peter Welch, Democrat of Vermont, said: “The fix is in. Republicans will get the votes. That’s the bad news. The good news is that Democrats stayed here all night and put up a spirited fight.”
For all of Mr. Trump’s characteristic bluster, the self-described king of the deal is treading gingerly on the actual policies in the bill. After members of the hard-line House Freedom Caucus complained that they were not being listened to by the House Republican leadership, Mr. Trump is seeking to bring them along by listening to their concerns before dictating his desires, his advisers say.
Influential groups representing hospitals and nurses came out on Wednesday against the Republican bill, joining doctors and AARP, the association of middle-aged and older Americans, to warn that it would lead to a rise in the uninsured.
For now, those advisers say, Mr. Trump is in listening mode. He had dinner on Wednesday with Senator Ted Cruz of Texas, who is leery of the House bill. He got an earful from conservative opponents of the bill when he met at the White House with representatives of the Heritage Foundation and Americans for Prosperity on Wednesday night.
In a letter to lawmakers, major hospital groups wrote, “As organizations that take care of every individual who walks through our doors, both due to our mission and our obligations under federal law, we are committed to ensuring health care coverage is available and affordable for all.”
On Thursday afternoon, the White House director of social media, Dan Scavino Jr., posted a photo on Twitter of the president sitting around a table at a meeting that Mr. Scavino said was budget-related. But among those at the table with the president were Representative Mark Meadows of North Carolina, the chairman of the Freedom Caucus, and Representative Jim Jordan of Ohio, two of the biggest obstacles to any health care bill deemed insufficiently thorough in obliterating the Affordable Care Act.
The groups, including the American Hospital Association, the Association of American Medical Colleges, the Catholic Health Association of the United States and the Children’s Hospital Association, said they could not support the bill “as currently written.”
The president has not spent enormous time negotiating specific aspects of the bill, people who have spoken with him say. But some of his advisers have been critical of the House Republican Conference, led by Mr. Ryan, for not doing more to bring along conservative members. The meeting at the White House with leaders of conservative groups was an effort to remedy that, Mr. Trump’s aides said.
The hospitals and the American Nurses Association joined the American Medical Association and AARP, which rejected the bill on Tuesday.
And in a sign of the White House still grappling with how tightly it wants to embrace the current bill, Vice President Mike Pence will appear instead of Mr. Trump on a trip to Louisville, Ky., this weekend. On Wednesday, Mr. Trump will hold a campaign rally in Nashville, where he is also expected to barnstorm for the repeal of the Affordable Care Act.
House Republicans have been left scrambling to marshal support from businesses and other interests that stand to benefit from lower taxes if the bill passes. Insurers are on the fence, and other powerful forces like pharmaceutical companies remain largely on the sidelines.
“The president will be visiting several cities over the next coming weeks to engage the American people on the need to repeal and replace,” Sean Spicer, the White House press secretary, said on Thursday.
Squeezed between wary health care providers and angry conservatives who say they believe that the bill leaves too much of the Affordable Care Act in place, the Republican leadership and President Trump appear to be facing an uphill climb.
Last week, Mr. Trump’s aides grew frustrated when the House Republican leadership bluntly told them that the president would need to use his political capital to bring people along. The tensions fall squarely in the purview of Reince Priebus, Mr. Trump’s chief of staff, who is close to Mr. Ryan and who some of the president’s advisers fear has divided loyalties. Mr. Trump vented his frustrations with Mr. Priebus last Friday over how much work remained toward preparing for the health bill rollout.
Senators from both parties continued to lodge their opposition. Senator Tom Cotton of Arkansas, a conservative Republican who has largely stuck with leadership, took to Twitter on Thursday morning to voice his concerns.
Mr. Trump’s advisers mostly welcomed the discussion of the bill as a reprieve from the controversy over Mr. Trump’s post on Twitter saying, without evidence, that he had information that Mr. Obama had “tapped” Mr. Trump’s phones at Trump Tower during the campaign.
Even the chief medical officer of Medicaid, Dr. Andrey Ostrovsky, broke with the leadership of the Department of Health and Human Services and endorsed the position of health care providers, opposing the Republican bill.
Those advisers are also aware that the rollout of the plan has been bumpy, with only deeply limited spade work done by the House Republican Conference to shore up outside support beforehand.
Among other proposals, Republicans on the Ways and Means Committee turned back Democratic amendments requiring that people not lose health coverage under the Republican legislation and that the plan not increase out-of-pocket costs for older people, a critical issue for AARP.
But White House advisers are well aware that they are saddled with the bill now. At the same time, they describe Mr. Trump as walking lightly — for him, at any rate.
The consideration by the Ways and Means Committee amounted to a procedural step on the way to a full House vote on the health plan. Hour after hour passed with Democrats airing their grievances about the legislation and offering symbolic amendments meant to get Republican members on the record about their views.
The vice president’s trip to Kentucky will bring Mr. Pence to a state that is being treated as ground zero in the repeal fight. Kentucky’s junior senator, Rand Paul, is the bill’s most prominent Republican critic. Its former governor, Steve Beshear, became a Democratic hero for successfully implementing the health care law in the deep red state, but Republicans took full control of its statehouse in elections last year despite the Democrats’ strong support for the Affordable Care Act.
“This is a historic step, an important step, in the repeal of Obamacare, and freeing millions of Americans, patients and local businesses from that pain,” said Representative Kevin Brady, Republican of Texas and the chairman of the Ways and Means Committee. He called the panel’s discussion “long but fruitful.”
There is some daylight between the House Republican leaders and the White House on how much change the bill can absorb. Representative Joe L. Barton, Republican of Texas, offered an amendment on Thursday that would have moved the health care bill in a conservative direction, reducing federal funds for the Affordable Care Act’s expansion of Medicaid at the end of 2017, two years earlier than under the legislation drafted by House Republican leaders.
The White House appears increasingly confident about the prospects for a health care overhaul to pass in the House. In a meeting with conservative leaders in the Oval Office on Wednesday, Mr. Trump said he anticipated the most trouble in the Senate, where moderate and conservative lawmakers are opposing the plan for different reasons. He said he was prepared to pressure holdout senators by holding the kind of stadium-style rallies he led during his presidential campaign.
Mr. Barton withdrew the amendment but hinted that it could reappear when the bill hits the House floor. The proposal was supported by two influential conservative groups, the Republican Study Committee and the House Freedom Caucus — and, he said, “the Trump administration is open to it.”
Speaker Paul D. Ryan said Republicans were “going through the inevitable growing pains of being an opposition party to becoming a governing party.”
Mr. Trump also wants the Republicans’ health care bill to inject more consumer choice into the process of selecting plans, said someone familiar with the president’s thinking, as well as the elimination of state-by-state insurance options. Such changes are impossible under the budget rules that Republicans are using to avoid a Democratic filibuster in the Senate.
“It’s a new system for people,” he added. “But it’s all the more reason why we have to do what we said we would do and deliver for the American people, and govern and use our principles.”
Representative McHenry said Mr. Trump talked in the meeting this week about how he had performed in the districts of lawmakers whose votes will be necessary.
The Energy and Commerce Committee worked through the night and was still at work when the sun rose shortly after 6 a.m. on Thursday.
The criticism of the bill from conservative groups grew so hostile so quickly that it surprised even Mr. Trump. In one of his first conciliatory gestures, Mr. Trump set out Wednesday to impress a half dozen conservative leaders in the West Wing with the ceremonial trappings of the presidency.
The committee rejected a Democratic amendment to preserve a part of the Affordable Care Act that provides low-income people with financial assistance to help cover deductibles, co-payments and other out-of-pocket costs for health care. The Republicans’ bill would eliminate these “cost-sharing reductions,” starting in 2020.
Initially, the group was told it would see the president in the Roosevelt Room. But after the group’s members waited there for a short while, an aide entered the room and said, “The president would like to see you in the Oval Office.”
“They are primarily in red states that you represent,” Representative Frank Pallone Jr. of New Jersey, the senior Democrat on the committee, told the Republicans. “These are your constituents. These are working people. They are not eligible for Medicaid. They are not getting health insurance on the job.”
Even so, it quickly became evident that the objections the activists had with the bill could not be washed away with the awe of the Oval Office. The president told them he did not appreciate the attacks on the proposal as “Obamacare lite” or something that fell short of a repeal. That kind of talk, he warned them, could be detrimental to their shared cause of gutting the Affordable Care Act.
Republicans said the Obama administration had spent billions of dollars on these subsidies even though Congress never appropriated money for the purpose. The Republican bill provides money to states that they can use to make health care more affordable, they said, and states could, if they wished, use those funds to help people with out-of-pocket costs.
Jenny Beth Martin, the president of the Tea Party Patriots, appreciated the attention.
The committee also rejected an amendment to eliminate the provision that would replace Medicaid’s open-ended entitlement with a per-beneficiary allotment of federal money.
“If the Republican leadership actually listened to voters or reached out to groups like the president did they’d have better legislation,” she said.
The array of groups taking strong positions against the bill is evidence that its potential consequences extend far beyond health insurance coverage, to much of the nation’s economy.
The opposition is also a powerful reminder of how many past efforts to overhaul the American health care system failed because of resistance by major interest groups. Winning the support of the health care and insurance industries allowed the Obama administration in 2010 to push through the most significant health care legislation since President Lyndon B. Johnson’s Great Society.
Within a few months after President Barack Obama took office in 2009, his administration had lined up support from health care providers, insurers, consumers and drug makers by offering a grand bargain: The health bill would include a requirement that most Americans have health insurance, providing millions of new customers through the law’s often substantial premium subsidies and its option for states to expand Medicaid. In exchange, hospitals would have to accept spending cuts and the health care industry would have to accept new taxes to pay for the legislation.
The Obama White House dedicated enormous effort to win pledges of support before Democrats even put out a bill — an effort not replicated by the Trump White House or Republican leaders in Congress.
But the Affordable Care Act also created an array of taxes that the Republicans now hope to wipe away, helping them win the support of groups like the United States Chamber of Commerce and Americans for Tax Reform, led by the anti-tax activist Grover Norquist.
The congressional Joint Committee on Taxation issued estimates this week showing how much revenue the government could lose starting in 2018 under the Republican bill, which the party has called the American Health Care Act, as a result of repealing taxes on drug makers (nearly $25 billion over 10 years), insurers (nearly $145 billion), makers of medical devices (nearly $20 billion) and high-income households (more than $270 billion from taxes on earned income and investment income).
“The American Health Care Act repeals the medical device tax, which will result in greater investments in medical cures, lower health care costs and more high-tech manufacturing jobs in communities across the United States,” trumpeted the Medical Device Manufacturers Association.
The extent to which these groups mobilize on behalf of the Republican bill may help determine whether it succeeds.
For now, the supporters of the House bill seem badly outgunned by opponents. On Wednesday, as two congressional committees took up the Republican repeal-and-replace bill, the American Nurses Association and the coalition of hospital groups came out against the proposal.
The A.M.A., which has nearly 235,000 members and calls itself the voice of the medical profession, sent a letter to leaders of the two committees on Tuesday saying it could not support the Republican bill “because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.”
In particular, the group said it opposed a plan to replace the sliding, income-based premium tax credits provided under the Affordable Care Act with fixed credits based on age. The current system, it said, “provides the greatest chance that those of the least means are able to purchase coverage.”
America’s Health Insurance Plans, the health insurance lobby, released its own lengthy statement on Wednesday. In a letter to the leaders of the House committees that drafted the bill, Marilyn B. Tavenner, the group’s chief executive, warned Republican leaders that their plans to change Medicaid financing, among other things, could harm coverage and care.
While many insurers have lost money in the Affordable Care Act’s private insurance marketplaces, they have generally profited from the expansion of Medicaid, which would effectively be phased out under the Republican plan.
“As a core principle, we believe that Medicaid funding should be adequate to meet the health care needs of beneficiaries,” Ms. Tavenner wrote. “Medicaid health plans are at the forefront of providing coverage for and access to behavioral health services and treatment for opioid use disorders, and insufficient funding could jeopardize the progress being made on these important public health fronts.”
A day earlier, AARP, which is another crucial supporter of the Affordable Care Act, had declared its opposition to the bill and had even started running an ad against it. In a letter to Congress, the group said the bill would increase health costs for people ages 50 to 64, could lead to cuts in Medicaid coverage of long-term care and would allow insurers to charge older people five times as much as younger ones.
The hardening resistance complicated the case for the Republicans as they moved their bill forward on Wednesday.
“I respect those organizations and their views,” said Representative Larry Bucshon, an Indiana Republican and a heart surgeon who conceded that criticism of the bill from doctors and hospitals could make it more difficult to sell the measure to the public. “Their voice is an important voice in health care.”
But, he noted, those groups supported the health care law in 2010.
“Hospitals have done quite well under the Affordable Care Act, but my constituents have not,” he said. “Their premiums are going up. Their deductibles are high.”
Across the rotunda, Republican senators were less enthusiastic.
Senator Shelley Moore Capito, Republican of West Virginia, said she was not certain that a delay in the rollback of Medicaid coverage was “enough for me.” Senator Lisa Murkowski, Republican of Alaska, expressed alarm that the bill’s tax credits would not account for higher premium costs in insurance markets like hers, a largely rural state with little competition. Senator Marco Rubio, Republican of Florida, said he did not want states that took the Medicaid expansion to “get a benefit” that the states that rejected the program did not.
“I want to make sure Florida is treated fairly,” he said.
Senator Susan Collins, Republican of Maine, said she was unhappy that the bill removed money for Planned Parenthood.
There was also a creeping concern about how quickly the bill was moving. Senator Mitch McConnell of Kentucky, the Republican leader, essentially promised to move the bill to the floor without the hearings and other processes that are normal for such a far-reaching piece of legislation. He had promised when Republicans took the majority that they would honor normal Senate processes and traditions.
“I think if that’s the approach they take,” Mr. Rubio said, “they won’t have the votes in the Senate.”
Senator John Cornyn of Texas, the No. 2 Republican, who will be charged with getting the bill over the line in the Senate, rejected the criticism. “There have been six or seven years of input,” he said. “We have to pass it because the alternative is the status quo.”
