In their effort to revamp the nation’s health-care system, Senate Republicans are considering preserving or more gradually eliminating key elements of the Affordable Care Act that the House voted to discard, creating an uncomfortable political situation for the party after years of promises to fully repeal the law.
Senate GOP leadership told rank-and-file Republican senators during private talks this week that they favor keeping guaranteed protections for people with preexisting medical conditions — a departure from the House approach of allowing states to opt out of a regulation ensuring such individuals are not charged more for coverage.
Senate Republicans have also been mulling options to more slowly roll back the expansion of Medicaid that most states accepted under Obamacare, and they are also openly talking about keeping many of the taxes the law imposed. The goal is to find a sweet spot of at least 50 votes in a sharply divided group of 52 Republican senators, many of whom are from states where coverage levels increased under President Barack Obama’s signature health-care law.
But Senate GOP leaders run the risk of alienating an influential trio of conservative senators — Ted Cruz (R-Tex.), Rand Paul (R-Ky.) and Mike Lee (R-Utah) — who previously demanded that the party follow through on promises to completely gut the law.
“I’m still pushing to try to make it better and make it more acceptable,” Paul said Thursday. He said Republicans might reach an impasse, in which case, “maybe we’ll just do a smaller repeal bill. That would pass. There’s a lot of stuff we don’t like about Obamacare that we agree on.”
Even some less aggressive critics of the law are uncomfortable with bluntly describing what the talks have largely become: a negotiation about how much of Obamacare to leave in place and for how long.
“Ah, well,” said Sen. Jeff Flake (R-Ariz.) before pausing to consider what to say next. “Depends how you phrase it, I guess. I mean, obviously, it’s there. We have to deal with it. We’re doing the best we can.”
Other Republican senators sought to play down any controversy about the parts of the law they are contemplating keeping in place.
“We think we’re repealing the most obnoxious parts of Obamacare,” said Sen. Charles E. Grassley (R-Iowa), who argued that “there are some parts of Obamacare that are completely nonpartisan, almost.”
But that nuanced posture stands in contrast to the way Republicans vilified the law in consecutive elections after it was enacted in 2010. They slammed Democrats who voted for it and campaigned repeatedly on the promise of repealing the law entirely if voters gave them control of Congress and the White House.
“I think we’re all adjusting to the reality of the current debate and what it takes to get across the finish line,” said Sen. Tim Scott (R-S.C.).
As he entered a Senate Republican health-care meeting on Thursday, Sen. Dean Heller (R-Nev.) said he believed the talks are indeed moving in a direction of preserving more of the law. Heller, who is up for reelection in a state that expanded Medicaid, said he supports a seven-year reduction of federal payments for people now covered under Medicaid.
Other Republicans from Medicaid expansion states, including Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.), said they favor the seven-year timeline. They envision gradually reducing the payments from 2020 to 2027, rather than the more abrupt rollback that would occur in 2020 under the House bill.
McConnell has proposed to senators the possibility of a three-year phaseout, according to a GOP senator familiar with the discussions who spoke on the condition of anonymity. McConnell has also personally proposed not including the House provision allowing states to opt out of the coverage cost protection for patients with preexisting conditions.
It could be difficult, though, to get conservatives to accept any of these provisions, since they have demanded that Obamacare regulations be slashed. Cruz, Lee and Paul have been coy in recent days about their position.
“The conversations are continuing,” Cruz said Thursday. “We still have a lot of work to do. What is most critical is that we honor our promise to repeal Obamacare and that we enact meaningful reforms to lower premiums.”
In February, the threesome launched a coordinated Twitter campaign to demand that the Senate fully repeal the law. “2 yrs ago, GOP Congress voted to repeal #Obamacare. That 2015 repeal language should be the minimum. #FullRepeal @SenTedCruz @SenRandPauI,” Lee wrote at the time.
They have sounded more open to compromise in recent months, particularly after the formation of a working group that Cruz helped create. But their history of bucking leadership at critical times has left lots of uncertainty about what they will ultimately do.
Still, some GOP staffers are cautiously optimistic about the chances of an agreement, even as the talks appear to be leaning toward keeping or delaying portions of the health-care law, including several tax provisions.
“Some taxes will probably stay in,” Sen. James Lankford (R-Okla.) said Wednesday. “We still need to have some way to fund whatever is going to happen.”
Senate GOP leaders have not yet identified which taxes they plan to keep to pay for things such as a longer Medicaid timeline and expanded tax credits.
But Lankford is one of many Republican senators who have already begun to openly embrace tax provisions the GOP once called some of the most onerous parts of the law.
Many GOP senators now view these taxes as a necessary evil in their quest to rewrite the health-care law while maintaining the deficit savings required by Senate budget rules. They are bound by strict requirements that the legislation reduce the deficit to take advantage of a procedure that would allow them to pass the bill with a simple majority of 51 votes, rather than the 60 needed to pass most legislation. This tactic, known as reconciliation, has also limited how much of Obamacare they can realistically undo.
Republican senators have been attempting to work out their differences in private meetings, and they are largely working without much input from the White House.
“They’re engaged,” said Sen. John Thune (R-S.D.), a member of Senate GOP leadership. “I think they’ll get more engaged when we have a bill.”
Thune and other leaders have said Trump played a crucial role in publicly selling the need to get rid of Obamacare.
But continuing questions about Trump’s interactions with top intelligence officials — including former FBI director James B. Comey, who testified at an attention-grabbing hearing on Thursday amid investigations into Russian meddling in the election — have also become a distraction.
Senate Democrats, who strongly oppose the emerging GOP bill, said that even if Republicans try to take less severe swipes at Obamacare than the House did, they will still be doing immense damage to people’s health-care options.
“No matter how they want to put lipstick on a pig, it is going to be a plan that devastates health care for millions of Americans,” said Sen. Patty Murray (D-Wash.).
Even some Republican senators who are expected to back any eventual health-care overhaul aren’t pleased with the compromises they find themselves forced to make. An unusually dour Sen. Lindsey O. Graham (R-S.C.) registered his frustration Thursday when asked whether the proposals emerging from the discussions amount to the repeal and replace of Obamacare he had hoped to achieve.
“I think it’s not repeal and replace,” Graham said. “I don’t think its repeal and replace.”