By Juliet Eilperin, Mike DeBonis and Elise Viebeck
WASHINGTON - A key committee in the House approved a Republican proposal to replace the Affordable Care Act before dawn on Thursday morning after roughly 18 hours of debate, awarding the bill its first procedural victory even as opposition mounted from conservatives, Democrats and health-care industry groups.
The House Ways and Means Committee voted 23-16 to advance the American Health Care Act shortly before 4:30 a.m. Committee Chairman Kevin Brady, R-Texas, called the move historic and praised President Trump, who has vowed to counter resistance to the bill with his own campaign-style effort.
“Ways and Means Republicans just passed legislation that will help Americans finally have access to affordable health care,” Brady said in a statement following the vote.
“This legislation reflects President Trump’s strong commitment to improving health care for all Americans. I sincerely thank my colleagues for their hard work and commitment to delivering on the President’s promise,” he said.
The passage of the bill through Ways and Means prompted furious responses from Democrats, who said Republicans failed to accept a single amendment from the minority party.
“We won’t back down from a fight to protect Americans’ health care,” committee Democrats wrote early Thursday on Twitter.
Major associations representing physicians, hospitals, insurers and seniors had leveled sharp attacks against the House GOP’s plan on Wednesday, as some Republicans publicly questioned whether the measure can clear the House of Representatives.
While industry groups warned that the proposal could leave vulnerable Americans with fewer protections than they now have, GOP leaders pressed ahead, bringing legislation before two key committees that are expected to approve the bills by week’s end. They were also working in concert with the White House to win over conservatives, who have complained that the proposal preserves too much of the current law.
The flurry of activity - including an evening meeting between President Trump and leaders from five skeptical conservative groups - created new uncertainty about the viability of Republicans’ signature promise to repeal and replace Obamacare.
Wednesday’s events also showed the uneasy predicament facing House Speaker Paul D. Ryan, R-Wis., the proposal’s chief booster, who described the plan as a “conservative wish list” that would deliver on years of GOP campaign promises to change the nation’s health-care system.
“Right now I feel confident saying there aren’t 218 votes for this,” said Rep. Scott Perry, R-Pa., a member of the conservative Freedom Caucus, who was referring to the number of votes needed to pass the measure out of the House. Perry opposes the proposal.
Thursday’s early vote showed that Ryan and other Republican House leaders are resolved to press ahead. Yet the proposal met a new round of GOP resistance in the Senate Thursday morning when Sen. Tom Cotton, R-Ark., wrote on Twitter that the House should “start over.”
“House health-care bill can’t pass Senate w/o major changes. To my friends in House: pause, start over,” Cotton wrote from his political account, rather than his official one. “Get it right, don’t get it fast.”
Cotton has been an outspoken critic of the swift pace at which House Republicans are moving ahead with their legislation. He has also held a town hall recently which grew heated amid impassioned questions by constituents deeply concerned about changes to the ACA.
The uninsured rate in Arkansas has dropped more dramatically than any state other than Kentucky from 2013 to 2016 according to Gallup.
“GOP shouldn’t act like Dems did in O’care,” Cotton wrote in a second tweet. “No excuse to release bill Mon night, start voting Wed. With no budget estimate!”
In another tweet, he wrote: “What matters in long run is better, more affordable health care for Americans, NOT House leaders’ arbitrary legislative calendar.”
Cotton’s tweet adds new uncertainty to the bill’s fate in the Senate should it pass the House. A quartet of other GOP senators in states that accepted Medicaid expansion under the ACA have already expressed concerns about the changes the bill would make to the way the program is administered.
Meanwhile, the bill taking fire on the right from Sens. Ted Cruz, R-Texas, Rand Paul, R-Ky., and Mike Lee, R-Utah, who say they want a more complete repeal.
The barrage of criticism shows how fraught the terrain of health-care policy is. It also reflects a backlash prompted at least partly by the breakneck speed with which House Republicans are trying to push through their proposal - with little upfront effort to work with interest groups or political factions.
“What we’re seeing now is that the political prospects for repealing the Affordable Care Act are as daunting as the effort to pass national health reform,” Larry Jacobs, a political science professor at the University of Minnesota’s Hubert H. Humphrey School of Public Affairs, said in an interview.
House Republican leaders have given little indication that they will make anything but marginal changes to their plan, which would eliminate the requirements that all Americans obtain coverage or pay a tax penalty and that businesses with at least 50 employees provide insurance. The American Health Care Act would replace income-based subsidies with refundable tax credits based on age and income, charge individuals a 30 percent surcharge if they buy a plan after allowing their coverage to lapse and phase out the law’s more generous Medicaid funding over time.
While conservatives complained that these changes don’t go far enough, they have sparked criticism not just from Democrats but from moderate Republicans, AARP, the American Medical Association and the American Hospital Association.
“We cannot support the AHCA as drafted because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations,” James L. Madara, chief executive of the American Medical Association and a doctor, wrote in a letter to committee leaders overseeing work on the bill.
Richard Pollack, CEO of the American Hospital Association, voiced similar fears, saying efforts to “restructure the Medicaid program” by shifting it from an entitlement program to one based on a per capita allocation “will have the effect of making significant reductions in a program that provides services for our most vulnerable populations and already pays providers significantly less than the cost of providing care.”
America’s Health Insurance Plans, the insurance industry’s largest trade association, sent a letter Wednesday saying that while it appreciated several of the proposed changes, the changes to Medicaid “could result in unnecessary disruptions in the coverage and care beneficiaries depend on.”
House Energy and Commerce Committee Chairman Greg Walden, R-Ore., told reporters Wednesday that critics were exaggerating the proposal’s potential repercussions.
“It’s tough to do entitlement reform, it’s tough to make these changes, but I think at the end of day, seniors are going to be fine,” Walden said. “If you’re on Medicaid today, you’ll be on Medicaid tomorrow. States can intercede here and help out. So there’s more to this story.”
Walden said it was “sort of shocking” that hospital groups were strongly opposing the plan, because the GOP legislation restores the ACA’s cuts to “disproportionate share” payments to hospitals that serve large numbers of uninsured patients.
“There’s a pretty big medical-industrial complex in America,” he added. “And when you touch it, I’ve discovered, it touches back.”
House Republicans’ determination to deliver on their promise to undo the ACA - Ryan said Wednesday that it is “the covenant we made with the American people when we ran on a repeal-and-replace plan in 2016” - has spurred a legislative drive that is happening at warp speed.
A cadre of lawmakers and staffers worked behind closed doors for several weeks to draft the pair of bills, which were designed to move through the annual budget process in order to clear the Senate with a simple majority vote.
But that process, which did not involve an extended period of negotiation with interest groups or consultation with Democrats, has produced a furious backlash.
Some insurers, including Molina Healthcare and the Alliance of Community Health Plans, said they did not get to offer any input into the House proposal.
“It doesn’t seem like the industry got any heads up or was involved. We definitely were not,” Sunny Yu, spokeswoman for Molina Healthcare, which has about a million members in the Affordable Care Act exchanges, said in an email.
Democrats threw up procedural obstacles Wednesday in the committee meetings and on the House floor, complaining that it was irresponsible to consider the bills before the Congressional Budget Office offered an analysis that showed the legislation’s impact on the budget and Americans’ overall health care coverage.
“We need to know, what this is going to cost?” asked Rep. Anna G. Eshoo, D-Calif., a member of the Energy and Commerce Committee. “We need to know, what kind of health insurance is going to be feasible?”
Both House Republicans and White House budget director Mick Mulvaney have predicted that they will have a CBO “score” ready by early next week, before the bills are combined and brought before the House Budget Committee. GOP staffers noted that other health-care bills, including the 21st Century Cures Act and the 2015 reauthorization bill for Medicare and the Children’s Health Insurance Program, began their journeys through congressional committees without a CBO score.
Democrats on the Energy and Commerce Committee moved to delay the bill’s consideration for 30 days, while those on Ways and Means moved to delay it for one week to allow for further hearings and to examine the CBO report. Both motions were voted down on a straight party-line vote, and the panels continued working into the evening.
Still, the most imminent threat GOP leaders must contend with comes from the far right. The speaker can lose only 21 Republican votes if the American Health Care Act is to pass, and opponents are promising to use that leverage to force changes to the bill.
Rep. Thomas Garrett, R-Va., a freshman member of the conservative House Freedom Caucus, said he was confident that his camp could help reshape the legislation. While Trump had endorsed it already, Garrett said, he would probably be willing to accept something else if it were changed in a way conservatives could support.
“This is a guy who said he wasn’t sure that NATO, in its classic role, is necessary - and then two months later we saw countries like Germany vow to increase their defense spending to 2 percent of GDP,” said Garrett. “Why’d they do that? Because Donald Trump wasn’t going to accept the status quo. They made a counteroffer. Right now, there’s an offer, and he’s saying he likes to get people to make counteroffers.”
Vice President Mike Pence met with two House Freedom Caucus leaders Tuesday, and that same day Mulvaney - a former caucus member - spent more than an hour at a meeting of the group. Its members have been invited to visit the White House next Tuesday.
Wednesday night, Trump met with leaders from Americans for Prosperity, the Club for Growth, FreedomWorks, the Heritage Foundation and its political arm, Heritage Action, and the Tea Party Patriots.
But the hard reality for Republicans is that any changes made to appease House conservatives could threaten the bill’s support among moderates.
“My fear is that the bill will go backwards,” said Rep. Tom MacArthur, R-N.J., a co-chairman of the centrist Tuesday Group who has gotten White House attention of his own: He met Tuesday with Health and Human Services Secretary Tom Price. “If the bill starts going in the reverse direction in order to satisfy certain members of my party, then I’m going to have a problem. I think the federal government has a role to play here, and I’m not looking to just see the federal government undermine the health-care needs of the American people.”
Sen. Susan Collins of Maine, a pivotal Republican moderate, said in an interview Wednesday with Yahoo News’ Katie Couric that the current House measure would “not be well received in the Senate” and stood no chance of passing as is. “I want us to slow down to take more time to be sure we get this right.”