The dispute within the Republican Party over health care widened further Friday as President Trump joined with two conservative senators in calling for an outright repeal of the Affordable Care Act if the party fails to agree on an alternative plan by the end of the July Fourth recess.
The reemergence of what has for much of the year been a fringe idea within the GOP revealed not only the party’s philosophical divide over how to revise Obamacare, but also senators’ growing anxiety that they are headed home to see their constituents with little to show them.
Sen. Bill Cassidy (R-La.) — who has said he cannot yet support the current draft of the Senate bill, because of the effects its cuts in Medicaid funding would have on his state — received a blistering reception at a Baton Rouge town hall Friday. As he sought to discuss flooding issues, an attendee interrupted to mention Medicaid, prompting others to chant, “Health care! Health care!”
“If you wish to chant and stop others from being able to speak or be heard, that is not civil,” Cassidy retorted.
Senate Majority Leader Mitch McConnell (R-Ky.) continued to work on forging a compromise that could garner sufficient support once his colleagues return to Washington on July 10. But Trump’s suggestion that Republican senators should switch gears and immediately try to repeal the ACA if compromise is elusive could embolden conservatives, making it harder for McConnell to broker a deal.
An early-morning tweet was Trump’s first public statement since taking office in favor of bringing down Obamacare with no replacement system in place — a move that could send the U.S. health-care system into deep turmoil.
“If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!” Trump tweeted.
Health industry officials have warned that overturning the existing law, which has extended insurance to roughly 20 million Americans and changed the rules under which insurance is offered across the country, would create chaos in a sector that accounts for one-sixth of the U.S. economy.
Robert Laszewski, president of Health Policy and Strategy Associates, said repealing the ACA without a replacement would be “a trauma” for an insurance market that needs regulatory clarity to set premium rates.
“There would be absolutely no certainty, whatsoever, about anything,” Laszewski said.
A June 2015 Congressional Budget Office analysis projected that such an outright repeal would add $137 billion to the federal deficit between 2016 and 2025 and leave 24 million non-elderly adults without health coverage between 2021 and 2025.
Two GOP senators who espouse this approach, Rand Paul (Ky.) and Ben Sasse (Neb.), welcomed Trump’s suggestion. But some of the high-ranking Republicans who have been working on the legislation rejected it as impractical, noting that it might force them to fashion a substitute with Democrats.
An even larger group of Senate Republicans suggested Friday that McConnell should scale back or cancel the chamber’s month-long August recess, given the lack of progress they have made on not just health care but a tax-code overhaul, spending bills, the debt ceiling and a budget resolution.
Senate Republicans David Perdue (Ga.), Steve Daines (Mont.), Joni Ernst (Iowa), John Neely Kennedy (La.), James Lankford (Okla.), Mike Lee (Utah), Mike Rounds (S.D.), Luther Strange (Ala.), Dan Sullivan (Alaska) and Thom Tillis (N.C.) sent McConnell a letter Friday asking him to shorten or cancel the August recess so they can get more done.
“Delivering meaningful results was never assumed to be easy, but the millions of Americans who placed their confidence in our leadership expect our full and best effort,” the 10 senators wrote.
Republicans are steeling themselves for attacks on their health-care negotiations over the July Fourth recess, with progressive activists planning to pressure any members of Congress they see at public events. Most GOP senators were keeping their plans close to their vests, though a handful, including Cassidy, Ted Cruz (Tex.), Susan Collins (Maine), Jerry Moran (Kan.) and Lisa Murkowski (Alaska) have announced town halls or parade visits.
Collins, a vocal critic of the current Senate draft, had publicized just one scheduled appearance — in the 1,300-person town of Eastport, Maine, near the Canadian border.
At Cassidy’s town hall at the Living Faith Christian Center in Baton Rouge, he tried to make the case for transitioning Medicaid recipients into private insurance. But constituents interrupted him repeatedly, prompting him to chastise them for being rude.
“I’ll tell you what’s rude — kicking 22 million people off of health care in this country,” said a man in the front row after the senator recognized him to speak.
The audience erupted into cheers.
Reminding Cassidy, a medical doctor, of his stint treating patients at a hospital for the uninsured, the man continued: “You worked at Earl K. Long for many years. You know what people are like at their lowest.”
Senate Democrats are staging events aimed at highlighting how the Senate’s draft bill could hurt health-care delivery in their home states. Sen. Heidi Heitkamp (D-N.D.) is visiting at least two rural hospitals over the break to underscore the impact of proposed funding cuts.
McConnell is trying to tweak his original proposal, which would make deep cuts in Medicaid while providing tax cuts to companies and wealthy Americans. The changes are part of an effort to bring on a handful of conservative and centrist senators who have questioned parts of the bill.
While it is unclear what specifically prompted Trump’s tweet, an aide to Sasse said that the senator had discussed the idea of a straight repeal privately with White House officials in recent days. On Friday, Sasse released a letter to the president suggesting that if an agreement is not reached by the day that members return from their week-long recess, the president should call on Congress to repeal the ACA and work through August to craft a replacement by Labor Day.
Paul, who retweeted Trump on Friday morning, later fired off a second tweet saying he had spoken to Trump and Senate GOP leadership “about this and agree. Let’s keep our word to repeal then work on replacing right away.”
And Americans for Prosperity’s chief government-affairs officer, Brent Gardner, whose conservative group is funded by Charles and David Koch, said the approach “has real merit.”
Deputy White House press secretary Sarah Huckabee Sanders said Trump did not see July 10 as a deadline to pass legislation. She added: “We’re still fully committed to pushing through with the Senate, at this point, but we’re, you know, looking at every possible option of repealing and replacing Obamacare. We are focused on doing that.”
Asked for the majority leader’s response to Trump’s Friday tweet, a McConnell spokeswoman said she did not have any new announcements.
Senate Republicans, along with their House counterparts, have repeatedly voted to abolish Obamacare without putting anything in its place, including as recently as 2015. In that Senate vote, only two Republicans dissented: Collins and Mark Kirk (Ill.), who lost his reelection bid last year.
House Ways and Means Committee Chairman Kevin Brady (R-Tex.) dismissed Trump’s suggestion that Congress could simply repeal parts of the ACA then go back and replace them later.
“That doesn’t achieve what President Trump set out to do,” he said during an episode of C-SPAN’s “Newsmakers” set to air Sunday. “I really think the Senate’s approach — certainly in the House — of not simply repealing but starting to put into place the elements that can make health care affordable . . . that should continue to be our goal.”
If Republicans use special budget procedures known as reconciliation to skirt a Democratic filibuster in the Senate to repeal the ACA, they could not immediately use the same procedures to replace it — meaning they would have to negotiate with Democrats.
“Democrats, no doubt, would obstruct any fair opportunity to replace the Affordable Care Act in the future,” Brady said. “So the very best opportunity to begin this good, thoughtful transition to affordable care is right now in reconciliation.”
But the calls for repeal reflect the anger that Trump and many conservatives feel about the measure McConnell crafted behind closed doors, which would cut $772 billion over 10 years from Medicaid, the public insurance program that covers nearly 70 million Americans, while providing $541 billion in tax cuts.
Chip Roy, who directs the Texas Public Policy Foundation’s Center for the Tenth Amendment Action and once worked as an aide to Cruz, said he believed that Trump’s tweet Friday was indicative of his “frustration with what’s going on on Capitol Hill.”
Senate leaders are rewriting their bill to provide $45 billion to combat opioid addiction and provide more financial assistance to low- and moderate-income Americans. They hope to win over conservatives by eliminating many of the ACA’s insurance mandates and allowing higher tax deductions through expanded health savings accounts.
But they have not settled on how they would finance all these changes, since conservatives oppose the centrists’ push to preserve one of the bill’s current taxes as a way of funneling more money to those who cannot afford health coverage on their own.
McConnell had hoped to get his proposed revisions to the bill to the CBO by the end of the week. By late Friday, the bulk of the anticipated changes resulting from the week’s negotiations had been sent to the office for review, two Republicans with knowledge of the process confirmed.
On Friday, Brady joined the chorus of conservatives who object to maintaining a 3.8 percent tax on investment income for high earners as a way of providing more money to low-income Americans in the health bill. The current draft repeals or delays all the taxes imposed by the ACA.
Keeping the tax, Brady said, would be a “tough red flag” if the bill comes back to the House.
Given the impasse, the bill continues to come under attack from the GOP’s right and center.
On a Friday conference call with reporters, officials with several conservative advocacy groups said it does not repeal the ACA forcefully enough.
“We believe that real repeal means full repeal,” said Andy Roth, vice president for government affairs at the Club for Growth. “Root and branch doesn’t mean trimming the hedges, as is currently the case.”
Ashley Cusick in Baton Rouge and Mike DeBonis, David Weigel and Ed O’Keefe in Washington contributed to this report.