© AP Photo/Alex Brandon House Speaker Paul Ryan of Wis., departs after speaking to the media after a Republican caucus meeting on Capitol Hill, Thursday, March 23, 2017, in Washington. President Trump delivered an ultimatum to House Republicans on Thursday night: Vote to approve the measure to overhaul the nation’s health-care system on the House floor Friday, or reject it and the president will move on to his other legislative priorities.
The president, through his aides, signaled that the time for negotiations was over with rank-and-file Republicans who were meeting late at night on Capitol Hill to try to find common ground on the embattled package crafted by House Speaker Paul D. Ryan (R-Wis.).
The move was a high-risk gamble for the president and the speaker, who have both invested significant political capital in passing legislation that would replace the 2010 Affordable Care Act. For Trump, who campaigned as a skilled dealmaker capable of forging a good deal on behalf of Americans, it could either vindicate or undercut one of his signature claims. If the measure fails, it would mean that Obamacare — something that congressional Republicans have railed against for seven years — would remain in place.
“Disastrous #Obamacare has led to higher costs & fewer options. It will only continue to get worse! We must #RepealANDReplace. #PassTheBill,” Trump tweeted from his official White House account as the meeting was wrapping up Thursday night.
It was far from clear, however, that Ryan and Trump have the votes to muscle the package through the House after several members of the hardline House Freedom Caucus refused to back it following a marathon session of negotiations Thursday with Trump and other top aides.
“We have been promising the American people that we are going to repeal and replace this broken law,” Ryan said. “Tomorrow we’re proceeding.”
But the speaker refused to answer shouted questions from reporters after the meeting about whether he had the votes to pass the health-care measure.
In a closed-door meeting with House Republicans Thursday night, according to Rep. Chris Collins (R-N.Y.), Office of Management and Budget Director Mick Mulvaney told his former colleagues “the president needs this, the president has said he wants a vote tomorrow up or down.”
“If for any reason it’s down, we’re just going to move forward with additional parts of his agenda,” Collins described Mulvaney as saying. “This is our moment in time.”
Ryan had intended to bring up his plan for a vote on Thursday. But criticism mainly from conservatives caused that strategy to unravel after Freedom Caucus members rejected Trump’s offer to strip a key set of mandates from the nation’s current health-care law.
“They’re going to bring it up, pass or fail,” said Rep. Mike Simpson (R-Idaho).
By evening leaders accepted the proposed change conservatives had rebuffed earlier, which would eliminate the law’s “essential benefits” that insurers must offer under the ACA. Those include covering mental-health treatment, wellness visits, and maternity and newborn care.
They also added one sweetener for moderates, a six-year extension of a 0.9 percent additional Medicare tax on high-income Americans who earn above $200,000 if filing individually, or $250,000 if married and filing jointly. By keeping the tax in place, GOP leaders could provide another $15 billion to help some older Americans obtain health-care coverage.
The negotiations over the legislation continued all day, even after leaders announced they would postpone a vote originally scheduled for Thursday. As evening came, members of the Freedom Caucus filed into the office of Ryan, as did White House Chief of Staff Reince Priebus and Trump’s chief strategist, Stephen K. Bannon.
Meanwhile, a new analysis by the Congressional Budget Office released Thursday evening showed that changes House leaders made to the bill on Monday do not alter a projection that 24 million more Americans would be uninsured by 2026 under the bill. In addition, the updated bill would cut the deficit by $150 billion over the next decade — nearly $200 billion less than the earlier version of the legislation.
The changes include a couple of conservative overhauls to the Medicaid program and language directing that $85 billion be used to help Americans ages 50 to 64 obtain coverage.
It was unclear how the new CBO score would affect legislative support for the bill, although Rep. Brian Mast (R-Fla.), who is undecided, said it is “one of the things I’m considering as we read the bill.”
“When we look at the CBO score, we remember the discrepancy between what they said about Obamacare and what took place,” he added, noting that the office had overestimated the number of Americans who would gain coverage as a result of the law. “But it should be a spoke in the wheel.”
The new score wazs not the leadership’s biggest problem. Speaking to reporters Thursday afternoon, the Freedom Caucus chairman, Mark Meadows (R-N.C.), said House leaders were still seeking another 30 to 40 votes to pass the bill.
“I’m desperately trying to get to yes,” Meadows said. “I think we need to make sure that it lowers health-care costs.”
House leaders confirmed that they still lacked sufficient support. And while conservatives posed the biggest challenge for House leaders, some key moderates are also against the bill.
Rep. Dan Donovan (R-N.Y.), who has known Trump for decades and whose Staten Island district swung heavily toward the Republican candidate, left the meeting committed to voting no.
“I’ve got to think about the 744,000 people I represent,” he said. Asked about the White House’s message that killing the bill would leave no more chances for repeal, he shook his head. “I don’t believe that.”
White House press secretary Sean Spicer said during an appearance Thursday night on Fox News that the president remained confident the bill would pass.
“At the end of the day, this is the only train leaving the station that’s going to repeal Obamacare,” he said, adding that Trump always knew winning a majority would be tough.
“I think we’re going to see the same level of success” as in last year’s campaign, Spicer said. “He’s left nothing in the field.”
Trump devoted much of his day to personally lobbying members, meeting with conservatives Thursday morning and offering to remove the essential benefits package from the proposal. Lawmakers who support that proposal say it would reduce premium costs for Americans.
But Freedom Caucus members have asked to eliminate more — including language that bars companies from setting insurance rates based on a person’s sex, medical condition, genetic condition or other factors. Their proposal would reverse the ban on lifetime or annual dollar limits on coverage, allow insurers to separate healthy and sick consumers into different risk pools, and undo the law’s requirement that large insurers spend at least 85 percent of what they collect in premiums on claims, and refund the rest.
The only existing mandates Freedom Caucus members are open to preserving are ones that bar insurers from denying coverage based on preexisting conditions and allow children to stay on their parents’ plans until age 26.
At least 80 percent of the group voted Thursday afternoon to reject the latest offer from GOP leadership and the White House.
“The ball is in their court,” said Freedom Caucus member Andy Harris (R-Md.). “Our position has not changed.”
The president continued to work on cajoling lawmakers throughout the day, meeting at 5 p.m. with members of the moderate Tuesday Group. Meanwhile, Ryan and House Majority Leader Kevin McCarthy (R-Calif.) huddled with about a half-dozen conservatives in the speaker’s office in an effort to win them over.
Trump, who spoke to a group of trucking executives and employees at a White House event aimed at showing how the ACA had driven up the industry’s costs, joked that he did not have much time to mingle.
“I’m not going to make it too long, because I have to get votes,” Trump said, sparking laughter. “I don’t want to spend too much time with you. I’m going to lose by one vote, and then I’m going to blame the truckers.”
As of Thursday afternoon, 37 House Republicans — mainly conservatives — had announced their opposition to the bill, known as the American Health Care Act.
But several Republican moderates are also balking at the bill. Members of the Tuesday Group and Freedom Caucus agreed to meet Thursday night to try to bridge their differences.
The ongoing effort to whip the vote, Rep. Joe Barton (R-Tex.) said, has involved “back-patting and butt-kicking.”
“Democracy’s messy,” he added.
This high-wire balancing act, in which Republicans are catering to conservatives in the House with the knowledge that they still must woo moderates to get legislation to Trump’s desk, could not only reshape the nation’s health-care system but could also have uncertain electoral repercussions for the new majority.
But with failure not a viable option, Ryan and Trump have been working furiously to win over the large voting bloc of conservatives who control the House bill’s fate.
Passage of the bill would represent a major political victory for both the White House and House leaders, although the ultimate fate of the legislation hinges on the Senate. There are at least a dozen skeptics of the bill among Senate Republicans, who maintain a slim 52-to-48 advantage, and many of them want to maintain some of the current law’s more generous spending components.
If Republicans fail this initial test of their ability to govern, Trump and Capitol Hill Republicans may face a harder time advancing high-priority initiatives on infrastructure, tax reform and immigration. They might also find themselves navigating strained relationships among themselves.
GOP leaders can afford only 22 defections, given that one Democrat was expected to be absent Thursday. A Freedom Caucus spokeswoman said that “more than 25” members of the group oppose the bill.
Democrats relished the GOP’s predicament. Members of the Congressional Progressive Caucus, who had scheduled a 4 p.m. rally against the bill, turned it into a short-term declaration of victory.
“Remember, they wanted to have their repeal and replace ready when Trump was inaugurated,” said Rep. Jan Schakowsky (D-Ill.). “Now, here we are — they don’t have it, again. They’re looking for a sweet spot, and they won’t find one.”
Former president Barack Obama, for his part, issued a statement noting that more than 20 million Americans have gained coverage since he signed the law in 2010, while the rise in health-care costs has slowed. The statement came on the seventh anniversary of the passage of the Affordable Care Act — a day that Republicans had hoped to mark by dismantling it.
“So the reality is clear: America is stronger because of the Affordable Care Act,” Obama said, adding that Republicans are welcome to work with Democrats to improve the law. “But we should start from the baseline that any changes will make our health-care system better, not worse, for hard-working Americans. That should always be our priority.”
Republicans’ current strategy is based on a new interpretation of Senate rules that raised the possibility that acceding to the Freedom Caucus’s request might not threaten Senate consideration of the whole bill. But aides said the provision could still be stripped out once the bill reaches the Senate.
Republicans can afford to lose the votes of only two senators, assuming Pence would step in to cast a vote for the health-care rewrite in the case of a tie.
In another example of last-minute tweaks, Illinois’ GOP delegation announced late Wednesday night that Centers for Medicare and Medicaid Services Director Seema Verma had assured them that “Illinois will have the opportunity to accurately report its 2016 Medicaid payment information to CMS.” The state “has long been disadvantaged by below- average Medicaid reimbursements,” the lawmakers said, and this adjustment will ensure that the state would receive more federal funds when the government shifts to allocating Medicaid dollars on a per capita basis under the bill.
David Weigel, Kelsey Snell, John Wagner, Paul Kane and Ed O’Keefe contributed to this report.