The Trump administration is in talks with congressional Republicans about making another push at repealing and replacing the Affordable Care Act.
The Republicans’ first proposal, the American Health Care Act, failed when the party could not shore up enough support for the bill that would leave 24 million Americans without coverage. The party was split between those who thought AHCA did too much to turn back Obamacare, and those who thought it did not do nearly enough. On March 24, House Speaker Paul Ryan was forced to cancel a vote on the bill at the last minute when it became clear he did not have the votes to pass it.
Republicans spent seven years campaigning on repealing and replacing the Affordable Care Act, and many are not ready to accept that initial defeat as the final word. They have begun new conversations about a different bill, that they hope could garner enough support from House Republicans to pass out of the chamber.
Conversations are quite fluid. Those discussions might end in another bill to repeal and replace Obamacare, or they could fizzle out without any proposal. Here’s where things stand right now.
What we know
The Trump administration is driving current health care talks. The House, particularly House Speaker Paul Ryan, spearheaded the last Republican health care effort.
But this push, numerous outlets report, comes from the White House. Vice President Mike Pence has met with both the House Freedom Caucus (about three dozen conservative Republicans) and the Tuesday Group (a smaller group of moderates) to discuss the possibility of a new health care compromise. Getting both these groups on board with any Republican health plan will be crucial if it’s going to pass the House.
As Rep. Morgan Griffith (R-VA) recently told Bloomberg, “If both the Freedom Caucus and the Tuesday Group can agree on some things, then we’re in good shape.” This is, of course, one of the biggest “ifs” of the debate right now — and one of the big unknowns in the process is whether an acceptable middle ground for both sides even exists.
The Freedom Caucus wants to repeal two key parts of the Affordable Care Act: the essential health benefits package and the community rating requirement. The essential health benefits require insurers to cover, at minimum, 10 categories of medical care including hospital trips, doctor visits, and maternity care. Community rating requires insurers to charge sick people the same prices as healthy people. Both are at the core of how Obamacare reformed the health insurance system; you can read a more in-depth explainer on those policies here. But the Freedom Caucus has made clear that the next bill must eliminate those policies to get them to vote for it.
There is not currently a bill or specific policy proposal that has grown out of these discussions. Freedom Caucus Chair Rep. Mark Meadows (R-NC) told reporters late Monday that they had not seen any official text that outlines what exactly the new health care plan might look like.
What we don’t know
How far health care discussions have actually gotten among Republicans. Notably, House leadership has tried to downplay the significance of the current negotiations. House Speaker Paul Ryan described the discussions as in “conceptual stages” in a Tuesday morning press conference. Ways and Means Chair Kevin Brady told reporters, “I don't know that there are any negotiations occurring; I know that there are conversations between members. There are lots of ideas being floated from all directions and that's very healthy.”
What type of changes Republicans will make. The Freedom Caucus has demanded, for example, that the new proposal end the essential health benefits. That seems to be on the table but there are also reports that it might not be in the final plan. BuzzFeed’s Paul McLeod writes that different groups of legislators walked away from White House meetings with different understandings of how that part would work.
So basically the White House met with GOP moderates yesterday and told them that essential health benefits are back in the health plan. But-— Paul McLeod (@pdmcleod) April 4, 2017
States can apply for a waiver of these benefits ONLY if they show that plan quality will increase, coverage will go up, etc. Then...— Paul McLeod (@pdmcleod) April 4, 2017
White House met with the Freedom Caucus (hardline conservatives) same day and implied they’d just approve any state who wants a waiver.— Paul McLeod (@pdmcleod) April 4, 2017
Whether we’ll ever see a new health care bill. There is a lot of space between policy discussions and legislation. There were reports Monday that a proposal would come out that night, but it didn’t happen. Meadows told reporters he expected to see text of a proposal sometime today. It might show up. It might not! We still don’t know whether these current talks will turn into an actual legislative proposal or fizzle out over the same issues that split Republican legislators on the last health care bill.
Whether there is enough common ground between moderate and conservative Republicans to ever pass a plan. Former Senate aide Chris Jacobs described a very deep, very serious divide among congressional Republicans in his obituary for the American Health Care Act:
Beneath the obvious tactical errors lie some fundamental disagreements within the Republican party and the conservative movement about Obamacare, the future of our health-care system, and even the role of government. As I have written elsewhere, those differences do not represent mere window-dressing. They are as sizable as they are substantive.
On the one hand, the conservative wing of the party has focused on repealing Obamacare, and lowering health costs—namely, the premiums that have risen substantially under the law. By contrast, moderates and centrists remain focused on its replacement, and ensuring that those who benefited from the law continue to have coverage under the new regime.
That divide between “repealers” and “replacers” represents a proxy for the debate between reducing costs and maximizing coverage, a debate that precedes Obamacare by several decades, if not several generations. Some have argued that facts on the ground—the individuals gaining coverage as a result of Obamacare—necessitate an approach focused on maintaining coverage numbers.
Finding common ground between the Republicans who want to roll back Obamacare entirely and those who want to maintain the coverage gains is not easy nor does it present a clear common ground. This is the hurdle that sunk the first Republican plan, and we don’t know if there is a strategy yet for overcoming it in this new debate.