Conservatives in revolt over GOP health care bill

WASHINGTON — After seven years of waiting longingly to annul President Barack Obama's signature health care law, Republican leaders Tuesday faced a sudden revolt from the right that threatened their proposal to remake the U.S. health care system.

The much-anticipated House plan to repeal the Affordable Care Act also drew skepticism from some of the party's more moderate members, whose constituents have benefited from expanded coverage in recent years.

The criticism came even before lawmakers knew the cost of the replacement plan and how many people might lose their health care if it were enacted.

House Republicans were rushing the legislation through two powerful committees — Ways and Means, and Energy and Commerce — with the hope of a full House vote next week, an extraordinarily compressed time frame considering that the legislation affects many parts of the U.S. economy and could alter the health care of millions of Americans.

But the swift opposition from fellow Republicans signaled that they might have to drastically reconsider their approach, and the White House portrayed the bill as a work in progress. If more than a dozen House Republicans defect, the bill will be in jeopardy, with Democrats almost certainly united as a bloc.

"Doing big things is never easy," House Speaker Paul D. Ryan conceded at a news conference Tuesday after absorbing broad-based criticism of the bill. Still, he guaranteed he would drum up the 218 votes needed for passage, saying, "The nightmare of Obamacare is about to end."

[Millions risk losing insurance in new plan, analysts say]

The Republican bill would eliminate the mandate for most Americans in favor of a new system of tax credits to induce people to buy insurance on the open market. It would also eventually roll back the expansion of Medicaid that has provided coverage to more than 10 million people in 31 states.

Vice President Mike Pence met Tuesday with conservative members of the House to assure them that their feedback was still being considered, and President Donald Trump entertained a group of House Republicans charged with persuading their colleagues to vote for the measure.

"We're going to do something that's great, and I am proud to support the replacement plan released by the House of Representatives," Trump said. "This will be a plan where you can choose your doctor, and this will be a plan where you can choose your plan. And you know what the plan is. This is the plan. It's a complicated process, but actually it's very simple. It's called good health care."

Some White House officials insist that Trump will be directly engaged in persuading lawmakers to back the bill.

But many of the factions that provided financial and political support to back Republicans who vowed to wipe out the Affordable Care Act are nowhere near satisfied with the option rolled out Monday.

"This is not the Obamacare repeal bill we've been waiting for," said Sen. Mike Lee, R-Utah, who was joined by a constellation of conservative groups, including the Club for Growth, Heritage Action for America and Charles G. and David H. Koch's Americans for Prosperity. "It is a missed opportunity and a step in the wrong direction. We promised the American people we would drain the swamp and end business as usual in Washington. This bill does not do that."

The Republican bill would scrap the mandated coverage in the Affordable Care Act in favor of tax incentives to coax people to purchase health care. But the legislation maintains many of the act's mandates and basic benefits, including prohibiting insurers from denying policies for pre-existing conditions or capping benefits in a year or a lifetime.

Some conservatives have labeled the House plan "Obamacare lite," saying it is nearly as intrusive in the insurance market as the law it would replace. In particular, they dislike the delay in getting rid of the law's Medicaid expansion. They also dislike the tax credits in the Republican plan, which can exceed the amount a consumer actually owes in federal income taxes, meaning that the Internal Revenue Service would be issuing checks to cover insurance premiums.

The House plan also maintains many of the demands on insurers that the Affordable Care Act has, including a defined suite of "essential benefits" that all insurers must offer.

Rep. Jim Jordan, R-Ohio, said that he would introduce a "clean repeal" bill and that Sen. Rand Paul, R-Ky., would offer a companion bill.

Republicans have been counting on Trump to use his influence to persuade wavering members to support the plan. But despite his characterization of the bill as "tremendous" Tuesday, others in his administration seemed to concede that changes, perhaps major ones, were likely.

Speaking to reporters after meeting with Senate Republicans at the Capitol, Pence offered the White House's imprimatur, calling the bill the "framework for reform." He added that the administration was "certainly open to improvements," making clear that the wrangling had just begun. Tom Price, the secretary of health and human services, said twice at a briefing with reporters at the White House that the bill was "a work in progress."

He also suggested that some provisions Trump is seeking, like the ability to buy insurance across state lines and the lowering of drug prices, might be addressed through regulation.

[Murkowski tells Legislature she'll consult Alaska leaders before voting on repeal of Medicaid expansion]

Rep. Mark Meadows, R-N.C., said Pence had portrayed the bill as a work in progress that would no doubt be amended, perhaps significantly. "The bill that was introduced last night is still open for negotiation and certainly for modification," Meadows said. "And we took that as very encouraging news."

Even with substantial changes, passage of the bill is in no way assured. House Republicans accomplished too little in shrinking the size of the government's role in the health sector to pull the most conservative members their way, yet they may not have done enough to allay the concerns of some Republican senators who are skeptical of elements like rolling back the Medicaid expansion and defunding Planned Parenthood.

In a radio interview Tuesday, Sen. Roy Blunt, R-Mo., said, "What I don't like is it may not be a plan that gets a majority of votes and lets us move on, because I think we can't stay where we are with the plan we've got now."

The response from insurers was largely muted Tuesday. They have praised the initial steps taken by the administration to stabilize the individual market, and they said they were encouraged by the desire to provide a smooth transition in the next two years. But several questioned the adequacy of the tax credits.

"It is important that the tax credit for 2020 creates a marketplace that enables people to get the coverage they need at a price they can afford," Alissa Fox, a senior vice president at the BlueCross BlueShield Association, said in a statement. "We look forward to working with Congress to create a stable and affordable private market."

By proceeding so swiftly, and largely in secret, Republicans have opened themselves to the same criticisms that they leveled at Democrats in 2010. If the bill is passed by the full House as early as next week, Sen. Mitch McConnell of Kentucky, the Senate majority leader, has promised to bring it immediately to the Senate floor without a single hearing.

"After years of howling at the moon about Democrats rushing through the Affordable Care Act — the mantra they said over and over and over again on the floor here and in the House, 'read the bill' — Republicans are having committee votes two days after the bill is released," Sen. Chuck Schumer of New York, the Senate Democratic leader, said on the Senate floor. "No wonder they don't want anyone to know what's in the bill."

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Thomas Kaplan and Jeremy W. Peters contributed reporting from Washington, and Reed Abelson from New York.