By Juliet Eilperin, Kelsey Snell and Sean Sullivan, The Washington Post
WASHINGTON — The Senate Republican plan for a scaled-back overhaul of the Affordable Care Act was headed for a cliffhanger vote when House Republican leaders said late Thursday that they were willing to use the proposal as a basis for negotiating a broader rollback of the law.
After a two-hour standoff, House Speaker Paul Ryan, R-Wis., issued a measured statement expressing openness to a House-Senate conference that many rank-and-file Republican senators have demanded as a condition for backing “skinny repeal” legislation that has little substantive appeal to them.
Ryan’s statement came as the Senate prepared for a marathon session of votes on health-care legislation that was expected to begin late Thursday and extend into Friday morning. The speaker also scheduled a pivotal meeting with his House caucus Friday to hash out the Senate’s demands.
“If moving forward requires a conference committee, that is something the House is willing to do,” Ryan said. “The House remains committed to finding a solution and working with our Senate colleagues, but the burden remains on the Senate to demonstrate that it is capable of passing something that keeps our promise.”
Although the statement could ease tensions, it remained to be seen whether it will be enough to win over a bloc of Senate Republicans who earlier had declared the proposal “terrible.”
“I would like to have the kind of assurances he didn’t provide,” Sen. John McCain, R-Ariz., told reporters.
Sen. Lindsey Graham, R-S.C., left open the possibility that he could be swayed by further talks, telling reporters he did “not yet” support the measure.
Earlier, McCain, Graham and Sen. Ron Johnson, R-Wis., convened a news conference as part of an extraordinary spectacle that highlighted the extent to which Republicans are struggling to reconcile their desire to tear down President Barack Obama’s landmark 2010 law with their inability to unite behind a replacement.
Republicans have been promising for seven years to repeal the Affordable Care Act (ACA) but never had a Republican in the White House to carry out their demands – until President Trump began urging lawmakers via speeches and tweets to send him something to sign.
McCain, Graham and Johnson – who could collectively defeat the Senate plan – said their support for a skinny repeal must not be used to trigger a hasty House vote before members head home for their August recess.
The commitment from Ryan alone wasn’t enough for McCain or Graham. McCain said Ryan’s statement did not go far enough to ensure that the legislation under consideration by Senate leaders would never pass the House.
“If I don’t get those assurances, I’m a ‘no,’ because I’m not going to vote for a pig in a poke,” Graham said. “I’m not going to vote for a bill that is terrible policy and horrible politics, just because we have to get something done.”
Many conservatives in both chambers object to the measure, which would remove key insurance mandates and make a handful of other changes, because they say it wouldn’t go far enough in repealing the ACA.
But, with lawmakers unable to agree on anything broader, it has become a last resort for Senate Majority Leader Mitch McConnell, R-Ky., to keep alive a longtime GOP promise. McConnell sent an email to Republican senators Thursday outlining the details of a skinny repeal.
The legislation would eliminate the law’s requirement that Americans obtain insurance or pay a tax penalty, and would suspend the mandate that companies employing 50 or more workers provide coverage for at least five years.
The measure also would eliminate funding for preventive health care provided under the 2010 law and block Medicaid recipients from being reimbursed for Planned Parenthood services. Finally, it would provide states more flexibility in how they administer their Medicaid programs under the law’s waiver program.
While the revamped health-care bill is more modest than earlier versions, it still would have a major effect on the individual insurance market. Eliminating the ACA’s individual mandate could transform the makeup of those buying coverage, causing the premiums for those remaining in the system to rise significantly.
Sara Rosenbaum, a health law and policy professor at George Washington University, said the bill would make “enormous” changes to both private and public insurance.
A preliminary Congressional Budget Office estimate has found that 16 million people would lose coverage and that premiums would rise 20 percent if Republicans enacted a handful of the policies included in the pared-down repeal bill.
Major insurers are warning that the proposal could destabilize the individual insurance market. Blue Cross Blue Shield Association criticized it on Wednesday, and on Thursday the industry’s largest trade group suggested it was unacceptable.
“We would oppose an approach that eliminates the individual coverage requirement, does not offer continuous coverage solutions, and does not include measures to immediately stabilize the individual market,” America’s Health Insurance Plans wrote in a letter to Senate leaders.
Senate Republicans, however, framed the bill as just a vehicle to keep alive their ACA repeal efforts.
“My sense is people aren’t so much focused on the substance as they are this being the lifeline to get to a conference and expanding the bill,” said Sen. Bob Corker, Tenn.
And Sen. Rob Portman, Ohio, tweeted, “I will support legislation to move this process to a House-Senate conference because I believe we need to repeal and replace Obamacare.”
Before Ryan issued his statement, the prospect of an immediate up-or-down vote in the House raised alarms in the Senate. House Republican leaders instructed their members not to leave town for their month-long summer recess just yet.
“Members are advised that – pending Senate action on health care – the House schedule is subject to change. All Members should remain flexible in their travel plans over the next few days,” said the office of House Majority Leader Kevin McCarthy, R-Calif.
Key House conservatives said they would not back a skinny repeal in its current form. Rep. Mark Meadows, R-N.C., chairman of the House Freedom Caucus, said that he wouldn’t vote for such a measure and that he didn’t think other conservatives would, either.
“My nose would say that there’s enough that it would lack the support,” he told reporters.
Speaking on the Senate floor Thursday, McConnell emphasized that the votes this week would not reverse the ACA even if they culminate in the passage of a bill.
“One phase of that process will end when the Senate concludes voting this week, but it will not signal the end of our work. Not yet,” he said.
Democrats, meanwhile, decided to save their political ammunition until Republicans revealed the substance of the skinny repeal measure.
Senate Minority Leader Charles Schumer, N.Y., said Thursday morning that Democrats will offer no more amendments until that point to prevent Republicans from claiming that their final bill was the product of extensive Senate deliberations.
Schumer said that if a skinny repeal passes, the Senate should be prepared for “numerous” Democratic amendments, which could force Republicans into politically tough votes.
In an effort to muster enough votes for a narrow bill, GOP leaders suggested that even some proposals that have died in the Senate could resurface once senators enter negotiations with the House. And some members tried to add a few more provisions to the skinny bill, using their leverage to try to strengthen their negotiating positions in conference.
Portman was pushing for the inclusion of $45 billion to treat opioid addiction, Republicans familiar with the talks said Thursday. It was unclear whether the funding would be included, given the bill’s budget constraints.
While McConnell has led the negotiations over health-care legislation for weeks, Trump has sought to drum up support by pressing wavering Republicans.
Interior Secretary Ryan Zinke called Sens. Dan Sullivan and Lisa Murkowski, both Alaska Republicans, separately Wednesday to warn them that the administration may change its position on several issues, according to people briefed on the conversations, given Murkowski’s vote against proceeding with health-care legislation this week.
Since Trump took office, Interior has indicated that it is open to constructing a road through the Izembek National Wildlife Refuge and drilling in the Arctic National Wildlife Refuge while expanding energy exploration elsewhere in Alaska. But now these policy shifts may be in jeopardy.
Speaking to reporters Thursday, Sullivan said the Trump administration has previously been cooperative on Alaska issues with Murkowski, who chairs the Senate Energy and Natural Resources Committee.
“From my perspective, the sooner we can get back to that kind of cooperation between the administration and the chairman of the ENR Committee, the better for Alaska and the better for the country,” he said. Sullivan said he is not telling Murkowski how to respond.
The Alaska Dispatch News first reported the calls; Interior officials did not respond to a request for comment.
As Republican senators prepared to plow ahead toward a final vote on the skinny repeal plan, the divides that have plagued their effort for months were still present Thursday, leaving open the possibility that new roadblocks could still emerge.
“I think there’s a lot of debate going on,” said Sen. Orrin Hatch , R-Utah.