It’s a rough week to be Paul Ryan.
Republicans’ first attempt at a replacement for Democrats’ health reform law was panned by enough GOP members to cast real doubt on whether repeal would ever pass. Now, the party has given itself just a few days to come up with a health care bill its members can unite behind, and the bill's GOP critics are pulling in opposite directions.
Centrist Republicans are worried about ending some of the most popular provisions of the Affordable Care Act, also known as Obamacare, which allowed millions of Americans to obtain health insurance for the first time. After a decade, 24 million additional Americans could be uninsured under the GOP plan, according to the nonpartisan Congressional Budget Office. Moderate Republicans want to make sure that the government does not abandon those who benefited from Obamacare.
That’s the opposite of the criticism coming from the GOP’s conservative wing. They feel that under the bill as written, the government would be doing too much in health insurance – continuing to help middle-class families buy coverage and regulating the plans that insurers can sell.
"The problem is, there are taxes, mandates and subsidies -- sounds a lot like Obamacare lite to me," Sen. Rand Paul (R-Ky.) said recently, summarizing the views of many conservative members of the House.
And if the party wants to pass any bill at all, it can’t write off either wing. With no Democrats expected to support the bill, 22 defecting House Republicans would be enough to sink it. Ryan and the GOP leadership have even less room to maneuver because Congress’s rules limit the kinds of changes they can make to the bill without exposing it to a Democratic filibuster in the Senate.
Ryan, in his official capacity as speaker of the House and his unofficial role as GOP wonk-in-chief, is the one tasked with making the legislative magic happen.
He and other party leaders get a shot at it Wednesday, when the House Rules Committee meets to consider changes to the bill before it gets a full vote on the House floor. If that vote is going to be successful, here are a few of the kinks the GOP will have to work out.
Many of the likely defectors in the Republican caucus are hard-line conservative lawmakers. Among their several objections is that the bill would do too little to constrain Medicaid, the federal program that provides health insurance to the poor.
Obamacare expanded Medicaid to cover more of the poor and more people who are near poverty. The current version of the GOP bill would largely preserve that expansion through 2020, and after that date, the law would grandfather in those beneficiaries who had joined Medicaid before and remained enrolled. Even those changes are likely to reduce Medicaid enrollment by a sixth after a decade and reduce spending on the program by $880 billion over that period, CBO estimates.
Conservative Republicans would like to undo the expansion immediately. They would also like to convert the program into a fixed payment to states, which could then use the money to the best of their ability to pay for health care for poor residents. In a House Budget Committee hearing last week, Republicans voted to recommend that the bill be revised to include block grants, as they're called, as an option in the final version.
Yet as GOP lawmakers revise the bill to appease their conservative colleagues, they will have to be careful not to drive moderate members away from the legislation. A block grant could mean that states are able to cover fewer of their residents. Accelerating the end of the expansion would also result in more Americans going without coverage, a troubling development for moderates already fretting over adding millions to the ranks of the uninsured.
"Doing that would be a nonstarter and would be enormously and hugely problematic for many of our members,” Rep. Charlie Dent (R-Pa.), a centrist congressman, told The Washington Post last week.
Under the Republican plan, the government would also continue helping working- and middle-class households buy health insurance. Conservative Republicans say this provision of the bill simply extends one of Obamacare's defining features.
In many cases, the benefits for these households would be substantially less generous under the Republican plan than under Obamacare. The benefits would be based on age, not income as in the existing system, so less affluent families that have enjoyed more generous subsidies under Obamacare would be especially burdened.
On the one hand, the new proposed benefits might not be generous enough to allow many Americans to pay for health insurance. The financial effects on those in older middle age -- many of whom CBO projects are likely to give up on buying coverage -- have been a particular sticking point for Republican lawmakers.
But even that current level of the benefits has turned off several conservative Republicans, who question whether the government should be providing the subsidies at all.
Alabama Republican Rep. Mo Brooks called the proposal "the largest welfare program ever sponsored by the Republican Party" in a recent interview with The Washington Post. And Rep. Jim Jordan (R-Ohio) has repeatedly called the GOP legislation's proposed system "a new entitlement."
All of the Republicans on the budget committee, including some of the most conservative lawmakers in the House, voted last week in favor of recommending that the proposal be revised to offer more financial help to less affluent households. That unanimous tally suggests that Republicans getting the bill ready for the floor might be able to win over moderate members without giving up conservative support.
Rather than relying on public benefits to help American families pay for insurance, conservative lawmakers argue that the free market can make health care affordable without the need for subsidies.
Jordan, the congressman from Ohio, called the Republican plan "subsidies for unaffordable health care, subsidies for unaffordable premiums," in a recent interview with The Post.
Right-leaning experts on health care argue that one source of costs in the system is Obamacare's requirement that insurance policies cover certain basic benefits, including routine services such as preventive and outpatient care. Instead, according to this reasoning, insurance companies should be allowed to offer bare-bones plans with cheap premiums that would not cover routine medical care, but would protect subscribers from bankruptcy in case of a severe and costly illness or accident.
The goal would be to reduce spending on health care nationally. Clinics and hospitals would mark down prices for routine services to compete for customers, who would scrutinize the value of the care they receive more carefully, reducing waste. Meanwhile, ordinary people would be able to protect themselves from catastrophic costs without paying exorbitant monthly premiums.
Yet the Republican bill does not repeal the regulations that Obamacare imposed on the kinds of policies insurance companies can offer. Some of Obamacare's rules are popular, such as the requirement that plans cover subscribers' children until they turn 26 and that companies cover patients regardless of their preexisting medical conditions.
At the same time, Republicans are using a congressional procedure to avoid a Democratic filibuster in the Senate that bars language not directly related to federal spending or revenue. GOP leaders are apparently concerned that legislation affecting how the insurance industry is regulated would not meet that requirement.
"Insurers need to be able to be freed from regulatory burdens that prohibit them from really offering those kinds of plans, and figuring out what people want to pay for," Strain said.