Paul Ryan concedes health care plan must change to pass House

House Speaker Paul Ryan said Wednesday that his health care proposal must change to pass the House, marking a significant retreat from his earlier position that the carefully crafted legislation would fail if altered.

The shift came after a private meeting of House Republicans from which Ryan, R-Wis., emerged to tell reporters that his proposal to revise the Affordable Care Act would "incorporate feedback" from the rank-and-file. Ryan attributed the change of strategy to the impact of an analysis issued Monday by the Congressional Budget Office. Among other details that prompted a fresh round of criticism of the proposal was a projection that 14 million fewer Americans would be insured after one year under the Republican plan.

Ryan backed away on Wednesday from his previous rhetoric of calling the measure's fate a "binary choice" for Republican lawmakers.

"Now that we have our score … we can make some necessary improvements and refinements to the bill," he said, referring to the CBO's estimate of the impact on the number of those covered by health insurance and what the GOP proposal would cost.

Ryan did not detail what changes are under consideration.

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Vice President Pence also spoke to House Republicans in the meeting, acknowledging that changes to the legislation – which heads to the House Budget Committee for approval Thursday – are in the works. President Trump has offered his support for Ryan's measure, while still meeting with conservative lawmakers who have expressed serious doubts about the plan.

"This president is ready to put the full weight of his bully pulpit and all of his tools" behind the bill, Pence told Republicans, according to Rep. Kevin Cramer, R-N.D. "It was very important for us to hear that, because there are a lot of people who need that shoring up."

Pence told conservatives that the plan was still under negotiation at a private lunch meeting of the Republican Study Committee, a large caucus of conservative House Republicans, according to several attendees.

"As he said, it's not often that we get an opportunity to undo such a big piece of legislation that had negative consequences on the American people," said Rep. Markwayne Mullin, R-Okla., paraphrasing Pence's message. "He's open to make improvements. … Anything that can get 218 votes and make the bill better, we're all about it."

Pence's visit to Capitol Hill – which included meetings with influential blocs of Republicans, as well as individual members – came as part of a White House effort to salvage support for the embattled American Health Care Act, even as President Donald Trump's conservative allies told him the bill could be a political trap.

The legislation will face an important test Thursday, when the House Budget Committee meets to consider the legislation and advance it to the House floor. The committee may not directly amend the bill but may make nonbinding recommendations. Any substantive changes would be made by the House Rules Committee, which controls how the bill is presented and debated on the floor.

House Budget Committee Chairman Diane Black, R-Tenn., insisted that GOP leaders are not "dug in" when it comes to concerns about the measure. "We're listening; we're definitely listening," she said Wednesday to conservative radio host Hugh Hewitt. "And I will tell you: Tune in to our Budget Committee tomorrow, and you will hear these conversations."

The blitz came two days after the Congressional Budget Office estimated that 14 million fewer Americans would be insured next year under the GOP plan. The falling coverage numbers and estimates of higher premiums for older and low-income Americans raised concerns among many lawmakers, particularly those representing states that expanded eligibility for Medicaid under the ACA.

Ryan, R-Wis., plans to hold a House floor vote next week, and Trump administration officials have spent the last two days in near-constant discussion with Republican lawmakers as they scramble to find enough votes to pass the measure. Leaders were set to take a preliminary count of members supporting the bill Wednesday night.

Critics of the legislation warned Wednesday that the measure remains far short of the 216 votes needed for passage. Typically, 218 votes are needed to pass a bill in the 435-member House, but five pending vacancies have reduced that threshold. No Democrats are expected to support the bill, and with 237 Republicans, party leaders can afford no more than 21 defections.

"They will whip it, and they will find 40 nos and another 30 or 40 undecideds," said Rep. Mark Meadows, R-N.C., chairman of the hard-right House Freedom Caucus, who has called for changes to mollify conservatives.

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One member of the Budget Committee who belongs to the Freedom Caucus, Rep. Dave Brat, R-Va., said he will vote against the bill in committee. Two other Freedom Caucus members, as well as three others on the panel, have not said how they will vote.

One conservative Budget Committee member who has voiced concerns about the bill said Wednesday that he had been convinced to advance it.

Rep. Glenn Grothman, R-Wis., said he would support the legislation in the panel based on an "implied promise that things are going to be different on the floor, and therefore we can keep the process moving."

He declined to say who had made that promise: "People higher up on the food chain than me."

"I'll say this, if the bill that comes to the floor is the exact same one in Budget, I'll feel a little bit that I'd been had," he said.

House Majority Whip Steve Scalise, R-La., acknowledged in an MSNBC interview Wednesday that the bill remains under negotiation.

"Watching sausage being made is not the prettiest thing," he said. "What can we do on those final pieces that are being negotiated with President Trump and a number of our members in our conference that ultimately want to get to a yes vote and send this bill over to the Senate?"

Ryan spent much of Tuesday and Wednesday giving interviews in an attempt to drum up support for the plan. On the Fox Business Network, he defended the plan as a collaboration with Trump and the Senate and said "the major components are staying intact" while opening the door to "refinements and improvements."

Later, in an interview with conservative radio host Laura Ingraham, he countered reports that the White House's support for the bill might be slipping. Ryan said he had spoken to chief of staff Reince Priebus and Trump's chief strategist Stephen K. Bannon "a number of times" about the bill, and he noted that Trump had brought lawmakers to the White House multiple times to make the case for the legislation.

"We are on the same page as the White House," Ryan said. "I think there are those who would love to wedge us for one reason or another, but that's just not the case."

Hours later, at a rally for Obamacare opponents outside the Capitol, Sen. Ted Cruz, R-Texas, told activists that the House plan "has a lot of problems" but could possibly be modified into a "real repeal" of the ACA.

"I believe we can get it done," Cruz said. "I can tell you, the last week, four days, I've been at the White House meeting with the president, with the vice president, saying, 'We've got to get it done.'"

Various changes have been floated since the bill was unveiled earlier this month. Conservatives have pushed for an earlier phase-out of the ACA's Medicaid expansion, moving it from the end of 2019 to the beginning of 2018, but GOP moderates in both the House and Senate have pushed back on that notion.

"Doing that would be a nonstarter and would be enormously and hugely problematic for many of our members," said Rep. Charlie Dent, R-Pa., a co-chairman of the centrist Tuesday Group.

Meadows said Wednesday that the Freedom Caucus is closely focused on repealing more of the ACA's mandates governing the extent of insurance coverage. "That is probably the No. 1 priority," he said. "If we can get those, it would make the rest of it a whole lot easier."

GOP leaders, however, have kept those provisions out of the pending legislation, arguing that their inclusion could threaten the bill's passage in the Senate and that many of those mandates can be undone through Trump administration actions.

In another sign of the effect of the CBO report, Sen. John Thune, R-S.D., floated a proposal to recalibrate the tax credits established under the House bill to offer more substantial help to low-income Americans. The House bill would offer assistance to individuals making as much as $115,000 a year; Thune's amendment would phase out aid for those making about $75,000 or more.

"We want to build on what the House has done, and we think that this amendment does that," Thune said. "It just makes it more defensible both in terms of the policy implications and the politics."

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The Washington Post's Kelsey Snell and Sean Sullivan contributed to this report.

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What’s next for the Affordable Care Act replacement bill

Republicans' first legislative priority is to "repeal and replace" the Affordable Care Act, more commonly known as Obamacare. Below is a guide to the three-phase process they plan to take.

By Kevin Schaul and Kevin Uhrmacher

Latest action: March 13

Bill scored by Congress's budget analysts

A Congressional Budget Office analysis of the bill estimated that 14 million additional people would be uninsured next year if AHCA were enacted. That number jumps to 24 million by 2026, partially because federal Medicaid dollars per person would be capped, imperiling the expansion of the program that took place in 31 states and the District of Columbia. The report also estimated a $337 billion reduction in the federal budget over 10 years.

The CBO is a nonpartisan scorekeeper that predicts the impact of legislation. Two House committees voted the legislation through before the CBO released its analysis, prompting criticism from Democrats.

Before it was released, some Republicans tried to pre-emptively downplay or discredit the report, with others calling on their House colleagues to pump the brakes and wait for the budget estimate before proceeding.

Expected this week

Bill moves to Budget Committee

Here, the two individual bills will be combined into one piece of legislation that will eventually go on to a full vote on the House floor. The Budget Committee chair, Rep. Diane Black, R-Tenn., will serve an important procedural role in the process.

Bill goes to the Rules Committee

The Rules Committee will consider amendments from the budget chair, Black, who works with leadership to find solutions that can help get the necessary votes for passage.

Planned for week of March 20

Bill must pass House

House Speaker Paul D. Ryan, R-Wis., has said he hopes to schedule the full floor vote for the week of March 20. Amid a chorus of complaints from the House Freedom Caucus and conservative think tanks, as well as moderate Republicans concerned about how many Americans could lose insurance coverage, it is unclear whether House leaders have enough votes.

Eventually

Bill must pass Senate

Because Republicans hope to pass this legislation under the less-onerous budget reconciliation process, House leaders must take care that the bill they pass will comply with the "Byrd Rule" in the Senate. Generally, the rule says a reconciliation bill must relate to the budget, which means some of the Affordable Care Act's provisions cannot be addressed via this process because they do not deal with taxes or spending. It also stipulates that the law cannot add to the deficit in the long term (10 years after it is implemented). It will be up to the Senate parliamentarian to decide whether the legislation meets the Byrd Rule standards.

The upside of doing it this way: Reconciliation bills are fast-tracked through the Senate and will need only 50 votes to be brought to a vote.

It's also possible that the Senate will do a significant rewrite of the legislation, moderating it but also setting up a showdown with House Republicans aiming for a more conservative approach.

If the House and Senate bills are not identical, a conference committee is formed

A group of lawmakers from the two chambers irons out the differences between the bills, which are then presented to both chambers for a final up-or-down vote.

President signs the bill into law

If Trump sours on the bill, he could decide to veto – effectively killing the legislation. Or he could sign it, kicking off the next phases of the Republican effort to dismantle the Affordable Care Act: further regulatory actions and additional legislation.

Last year, an Affordable Care Act repeal bill cleared both houses but was promptly vetoed by President Barack Obama in defense of his signature policy accomplishment.

Administrative actions

Beyond the AHCA, Republicans have outlined two other phases of health care overhaul. The first of those is an easing of regulations, begun by Trump's Jan. 20 executive order telling federal agencies to "minimize the unwarranted economic and regulatory burdens" of the Affordable Care Act. Regulatory reforms could include narrowing the list of benefits that the Affordable Care Act requires insurers to cover.

Additional legislation

Because only budget-related items are allowed in a reconciliation bill, Republicans also plan to address other aspects of the replacement with at least one other piece of legislation. This bill would be subject to the filibuster, requiring 60 votes – and at least eight Democrats – to get to a Senate floor vote. It could include allowing people to buy insurance across state lines.

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Source: Staff reports, Committee for a Responsible Federal Budget, Congressional Budget Office (PDF). Published March 13.