Trump concedes health law overhaul is 'unbelievably complex'

WASHINGTON — President Donald Trump, meeting with the nation's governors, conceded Monday that he had not been aware of the complexities of health care policymaking: "I have to tell you, it's an unbelievably complex subject. Nobody knew that health care could be so complicated."

The president also suggested that the struggle to replace the Affordable Care Act was creating a legislative logjam that could delay other parts of his political agenda.

Many policymakers had anticipated the intricacies of changing the health care law, and Trump's demands in the opening days of his administration to simultaneously repeal and replace President Barack Obama's signature domestic achievement made the political calculations far more complicated.

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Governors of both parties added still more confusion on Monday when they called for any replacement to cover all the people already benefiting from the landmark law.

"Of course I am concerned," said Gov. Brian Sandoval, the Republican governor of Nevada, where about 300,000 people have gained Medicaid coverage. "I am someone who elected to expand Medicaid. That's been very beneficial to my state, and I want to be sure those individuals can keep their coverage."

"Governors are all in agreement," said Gov. Terry McAuliffe of Virginia, a Democrat who is the chairman of the National Governors Association. "We do not want one single one of our citizens to lose access to quality health care. We are all unified on that. Actually, we want to expand, so everybody has access to quality health care."

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Trump brushed aside opinion polls suggesting that the 2010 health law was becoming somewhat more popular. "People hate it," the president said, "but now they see that the end is coming and they're saying, 'Oh, maybe we love it.' There's nothing to love. It's a disaster, folks."

Because of the intricate procedures that govern budget legislation and the inherent complexity of health care, Republicans appear unlikely to undo the health law as quickly as they had hoped. Trump said Congress must tackle the Affordable Care Act before it can overhaul the tax code, also a high priority for Republicans. And those delays could slow work on other priorities like a billion-dollar infrastructure push.

"Statutorily and for budget purposes, as you know, we have to do health care before we do the tax cut," Trump told governors.

After his session with the governors, Trump met on Monday with executives from health insurance companies. He apparently hopes they will stay in or return to the Affordable Care Act's insurance marketplaces, where more than 10 million people obtained coverage last year.

If the governors' meeting in Washington was supposed to clarify the future of the health law, it fell short. If anything, it exposed deep divisions among state executives, especially Republican leaders.

Gov. Gary R. Herbert of Utah, a Republican, said: "We did not expand Medicaid. Many states are divided on what the right approach is to take under the Affordable Care Act." Some Republican governors, he said, are concerned about the "sustainability" of the Medicaid program, which covers more than 70 million low-income people.

And no governor was ready to say publicly that he or she could accept a replacement health law covering fewer people than the Affordable Care Act, which has extended coverage to 20 million Americans.

A bill drafted by House Republicans could cover fewer people. It would roll back the heath law's expansion of Medicaid, eliminate tax penalties for people who do not have health insurance and end taxes imposed by the Affordable Care Act on certain high-income people, insurers, drug companies and manufacturers of medical devices.

To help people buy insurance, if they do not have coverage at work or under a government program, the bill would offer tax credits ranging from $2,000 to $4,000 a year, depending on age. But the credits would not fluctuate with a recipient's income, raising the prospect that insurance might be less affordable for lower-income people.

The House Republican bill would also eliminate minimum federal standards for "essential health benefits," and it could require some people with particularly expensive employer-sponsored coverage to pay taxes on some of its value.

The emergence of that draft has produced cries of opposition among Democrats and nervousness in some Republican quarters. Conservatives added their objections on Monday, saying the tax credits could become a permanent entitlement. Rep. Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said he could not vote for the bill in its current form because it could create "a new health insurance entitlement with a Republican stamp on it."

Herbert said he could support the Republican proposal to give each state an allotment of federal money with a set amount for each Medicaid beneficiary — what he and other officials described as a per capita cap. Some experts believe that could be "the best thing for us to do in Utah," Herbert said.

But Democratic governors generally oppose efforts by congressional Republicans to give each state a fixed allotment for each beneficiary or a lump sum, known as a block grant, for its entire Medicaid program.

"Block grants or per capita caps would throw state finances into disarray" and shift costs to the states, Democratic governors said in a letter to congressional leaders.

Two House committees may try to vote next week on legislation to repeal the Affordable Care Act and put in place some elements of a replacement. But the disagreements among Republicans, in the Trump administration and on Capitol Hill, suggest a difficult road ahead.

In recent days, some senior White House officials have come to believe that the timetable House Republicans have laid out for the health care overhaul is overly ambitious, said one person who has been briefed on their thinking, given the apparent public opposition to what is known of the plan already and the likelihood that an independent cost-benefit analysis could make it even less attractive to low-income voters.

If the House plan fails, these officials may introduce a White House version of the repeal-and-replace legislation later in the year, with the hope that it will be better received, added the person briefed on the matter.

Gary Cohn, the director of the president's National Economic Council, and his staff have spent significant time studying the Affordable Care Act and its weaknesses. Cohn and Jared Kushner, the president's son-in-law and a senior adviser to him, have emerged as skeptics of the plan being developed by House Republicans, said the person briefed on the matter. The White House had no immediate response to a request for comment.

The White House chief of staff, Reince Priebus, is more aligned with the House speaker, Paul D. Ryan, and the secretary of health and human services, former Rep. Tom Price, who are championing the current repeal-and-replace bill.

Trump's Treasury secretary, Steven Mnuchin, said as recently as Thursday that the administration hoped to pass tax cuts for both businesses and middle-class Americans in time for Congress' recess in August. But since health care must be addressed first, tax legislation could easily be pushed into 2018, according to members of Congress and administration officials.