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House Republicans unveil changes to their health care bill

The Washington Post logoThe Washington Post 3/21/2017

House Republican leaders, racing toward a planned Thursday vote on their proposed health-care overhaul, unveiled changes to the legislation late Monday that they believe will win over enough members to secure its passage.

The changes addressed numerous GOP concerns about the legislation, ranging from the flexibility it would give states to administer their Medicaid programs to the amount of aid it would offer older Americans to buy insurance. They are the product of two weeks of negotiations that stretched from the Capitol to the White House to President Trump's Florida resort.

The bill's proponents also appeared to overcome a major obstacle Monday after a key group of hard-line conservatives declined to take a formal position against the bill, known as the American Health Care Act.

The House Freedom Caucus has threatened for weeks to tank the legislation drafted by House Speaker Paul D. Ryan (R-Wis.), arguing that it does not do enough to undo the seven-year-old Affordable Care Act. If the group of roughly three dozen hard-right GOP members uniformly opposed the bill, it could block its passage. Their neutrality gives the legislation a better chance of passage when the bill is expected to hit the House floor later this week.

Rep. Mark Meadows (R-N.C.), the caucus’s chairman, said Monday that while most members of the group remained opposed to the bill, they would not choose to require members to oppose the bill on the floor. That frees House leaders and White House officials to persuade individual Freedom Caucus members to support the measure — a process that Meadows acknowledged was already underway.

“They’re already whipping with a whip that’s about 10 feet long and five feet wide,” he said. “I’m trying to let my members vote the way that their constituents would want them to vote. . . . I think they’re all very aware of the political advantages and disadvantages.”

House leaders hope to pass the bill Thursday and then send it to the Senate. Trump himself is expected to press for the bill’s passage in a Tuesday morning meeting with Republican lawmakers.

Some of the changes unveiled Monday were made to placate conservatives, such as accelerating the expiration of the ACA's taxes and further restricting the federal Medicaid program. But a major push was made to win moderate votes, including a maneuver that House leaders said would allow the Senate to beef up tax credits for older Americans who could see major increases in premiums under the GOP plan.

There were signs Monday that the bill had growing support among the moderate wing of the House GOP. Rep. Tom MacArthur (R-N.J.), who had voted against the leadership in an early procedural vote on the health-care legislation, said that he was “satisfied enough that I will support the bill.”

MacArthur said he was assured that the bill would do more for older and disabled Americans covered under Medicaid and that an additional $85 billion in aid would be directed to those between ages 50 and 65. “That’s a $150 billion change in this bill to help the poor and those who are up in years,” he said.

The Freedom Caucus had pushed for a variety of alterations, from an earlier phaseout of the ACA’s Medicaid expansion to a more thorough rollback of the insurance mandates established under the law. But for political and procedural reasons, few of the group’s major demands stand to be included in the bill.

“It’s very clear that the negotiations are over,” said Meadows, who met with White House officials at Trump’s Mar-a-Lago resort in Florida on Saturday. “To suggest that there are going to be any substantial changes between now and Thursday would go against everything that we are being told.”

Many Freedom Caucus members remain sharply opposed to the legislation. “While I’ve been in Congress, I can’t recall a more universally detested piece of legislation than this GOP health care bill,” Rep. Justin Amash (R-Mich.) tweeted Monday.

But under the group’s rules, 80 percent of its members must agree in order to obligate the entire Freedom Caucus to vote as a bloc. No Democrats are expected to support the bill, meaning Republican leaders can afford to lose no more than 21 of their own members.

Meadows said the Freedom Caucus would consider introducing amendments to the bill and asking for a floor vote on them — but he did not expect the leadership-controlled Rules Committee to allow them to come to a vote. “I don’t think that the bill will pass without substantial changes,” Meadows said, but he added: “I’m not that bold to suggest that no one will change their mind between now and Thursday. In fact, I already know of people who have changed their mind.”

Trump’s visit to the Hill on Tuesday signals that GOP leaders and the president consider larger-scale talks with key blocs of House members to be essentially complete. The effort now turns toward persuading individual members to vote for the package, and there is no bigger point of leverage than Trump himself.

Speaker of the House Paul Ryan (R-WI) speaks to the media on Capitol Hill in Washington, U.S., March 16, 2017. © REUTERS/Joshua Roberts/File Photo Speaker of the House Paul Ryan (R-WI) speaks to the media on Capitol Hill in Washington, U.S., March 16, 2017. “The president is bringing people to his table, and I’m very impressed with how the president is helping us close this bill and making the improvements that we’ve been making, getting the votes,” Ryan said in a Fox News interview Sunday. “We are right where we want to be.”

The hard-line conservatives have resisted the entreaties, arguing the bill does not do nearly enough to reverse the ACA and lower the price of health insurance coverage. They have been emboldened by several conservative Republican senators who also want to make major changes to the legislation.

Sen. Rand Paul (R-Ky.), who has worked closely with the hard-right bloc in the House, said Sunday on ABC’s “This Week” that Freedom Caucus members “still believe that the conservatives in their caucus don’t want Obamacare lite” and that the bill remained short of a majority. “I believe that the real negotiation begins when we stop them,” he said, referring to Ryan and House GOP leaders.

But Ryan expressed confidence that the bill would pass the House this week — and then move to the Senate, where the legislation is facing even sharper doubts and the GOP majority is much narrower. He cited the president’s hands-on involvement as a key factor in moving the legislation forward.

Trump’s visit Tuesday will be his first appearance at the weekly House Republican Conference meeting since becoming president. He last privately addressed Republican lawmakers as a group at the party’s policy retreat in Philadelphia in late January and has met with small groups of members on several occasions since.

Trump won the backing of several conservative House members Friday when he agreed to make changes to the Medicaid portion of the bill, including giving states the option of instituting a work requirement for childless, able-bodied adults who receive the benefit. Those changes are expected to be included in the leadership-backed amendments that will be incorporated into the bill before it comes to a final vote.

To address concerns expressed by a broader swath of GOP lawmakers — conservatives and moderates alike — the bill also is likely to be changed to give older Americans more assistance to buy insurance, Ryan said Sunday.

A CBO analysis forecast a short-term increase in premiums under the GOP law and said that premiums are expected to be 10 percent lower over the next 10 years than they would be if the ACA remained in place. But some older and low-income people would face massive premium hikes.

In an extreme case laid out in the CBO report, a 64-year-old earning $26,500 a year would see yearly premiums rise from $1,700 under the ACA to $14,600 under the Republican plan.

Ryan has disputed that analysis, suggesting that administrative actions taken by the Trump administration would further lower premiums and questioning whether the ACA would remain viable in a decade. But he acknowledged Sunday on NBC that the GOP bill would probably have to change.

“We believe we should have even more assistance, and that’s one of the things we’re looking at for that person in the 50s and 60s because they experience higher health-care costs,” he said.

Kelsey Snell contributed to this report.

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