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Trump’s words on Obamacare stir up intraparty feud

By Mike DeBonis

WASHINGTON – President Trump ascended the bulliest of pulpits Tuesday to address a joint session of Congress. It turns out it was his fellow Republicans who needed some bullying - specifically, on their plans to repeal and replace the Affordable Care Act.

The leader of the Republican Party took some tentative steps in his address to the joint congressional session toward a position in the Obamacare fight currently looming over Capitol Hill. But the president’s words sparked as much debate as they quashed.

The federal government, Trump said, “should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts.”

By specifically mentioning “tax credits,” Trump appeared to side with House Speaker Paul Ryan, R-Wis., in a key intraparty debate over what the ACA’s replacement ought to look like. Influential conservatives in the House and Senate have balked at offering refundable tax credits to help Americans buy insurance, advocating instead for a less expensive tax deduction.

Ryan’s staff and House GOP leaders immediately claimed Tuesday that Trump had moved to settle the dispute.

“This was clear sign that President Trump is working in sync with us in the House and Senate and wants to make sure we get this done quickly,” said Rep. Steve Scalise, R-La., the House majority whip. “We’ve laid out a lot of specifics, and I think you saw the president embrace and endorse a lot of those key components tonight.”

But on Wednesday, with GOP congressional leaders heading to the White House for a working lunch and key House committee chairmen set to brief Republican senators on their health care plans,there was still significant unrest.

Rep. Kevin Brady, R-Texas, chairman of the House Ways and Means Committee, and Rep. Greg Walden, R-Ore., chairman of the House Energy and Commerce Committee, are scheduled to brief GOP senators Wednesday afternoon in a bid to build bicameral consensus on the developing House framework.

One big fault line is what do with Medicaid, the government’s health program for low-income Americans that was expanded to 11 million people as part of Obamacare.

Trump did not say anything about how to handle Medicaid in any overhaul and some Republican senators in 31 states where coverage was extended haveremain wary of plans that independent consultants say could reduce the coverage rolls and open gaping holes in state budgets.

Rep. Mark Meadows, R-N.C., chairman of the House Freedom Caucus and an outspoken critic of refundable tax credits, said that he did not believe Trump’s remarks were a full-throated endorsement of the Ryan plan.

“I didn’t interpret it to mean that it was advanced or refundable,” he said, referring to the nature of the tax credits. “It reinforces the continued need to find common ground on a path forward.”
The tax credit issue has become a symbol of the fight between the House GOP leadership and its conservative flank and the amount of government spending it would take to achieve adequate health coverage in the ACA’s absence.

Some would like to see a refundable tax credit that would provide the same sum to taxpayers of all income levels, even those who pay little income tax because of their low incomes. Others would like to see upfront credit - distributed throughout the year - to spare insurance buyers from having to pay their premiums in full before seeking reimbursement on the following year’s tax return.
Conservatives like Meadows have argued that refundable tax credits are too expensive and constitute a new federal entitlement; while upfront credits, they say, are too prone to fraud and abuse. But they have been a part of past GOP plans – including Ryan’s “Better Way” blueprint and an ACA replacement plan advanced by new Health and Human Services Secretary Tom Price when he was a House member, one that many conservatives, including Meadows, co-sponsored.

Other key conservatives kept their powder dry Wednesday. Sen. Ted Cruz, R-Texas, perhaps the ACA’s fiercest critic in the Senate, declined to say whether he would support or oppose a GOP health-care bill that included tax credits.

“We should focus on areas of consensus,” Cruz said. “I understand that our good friends in the media want to focus on areas of division. ... I think the president laid out general principles of reform, and right now both houses of Congress are debating the specifics of those reforms.”

Senate Republicans can scarcely afford any internal dissent. GOP leaders are hoping to use special budget rules to pass an ACA repeal bill by a simple majority vote - but even so, they can lose no more than two of 52 Republican senators.

One Republican, Sen. Rand Paul of Kentucky, has put forth a tax-deduction-based plan that has been embraced by hardline House conservatives and is already seen as unlikely to support any plan involving tax credits.

GOP lawmakers of all ideological stripes said that Trump needs to take a more aggressive role in refereeing the intraparty disputes and keeping lawmakers on course toward delivering on their shared campaign promises.

“You get the big microphone as a chief executive, and from the standpoint of signaling on complex bills – whether that’s tax reform, what happens next on health care – presidential involvement and leadership is vital,” Rep. Mark Sanford, R-S.C., a former governor of his state, said Tuesday before Trump’s speech.

Sanford has put forward his own tax-deduction-based health-care bill, similar to Paul’s, and he acknowledgedthat if Trump supports tax credits, things would become challenging.

“It becomes very difficult for Republicans to go a different course, although I would hope that we would,” Sanford said.

Trump has shown a willingness to prod and cajole congressional leaders into action. At one point soon after his election, he floated asking Congress to call a “special session” to move forward with the ACA’s repeal – never mind that Congress was already scheduled to meet at the time. He has also invited dozens of lawmakers to the White House, including Wednesday afternoon’s lunch.
But it remains to be seen how willing he’ll be over the coming weeks to intervene in intraparty squabbles and keep his legislative agenda from drifting off the rails.

Ryan said Trump speaking out on tax credits is a sign that he will be unafraid of stepping up when necessary.

“Tonight was a big night for Republicans’ efforts to repeal and replace Obamacare,” said Ryan spokeswoman AshLee Strong Tuesday. “These comments demonstrate that the White House and Congress are coalescing around a particular approach that will help us keep our promise to the American people to repeal this broken law and replace it with a better system.”

Rep. Chris Collins, R-N.Y., an outspoken Trump ally, said fellow GOP lawmakers are entitled to share their views but will ultimately need to support the party’s consensus plan.

“We as a Republican party have to get this passed, otherwise next term’s midterm elections would not be a pretty sight,” he said. “They’re putting their marker down, but we all campaigned on repealing and replacing Obamacare. When a good bill finally hits the floor would they really vote against it?”

Ed O’Keefe and Sean Sullivan contributed to this report.

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