By Thomas Kaplan and Robert Pear
WASHINGTON – With two days left before an 11-day recess and no vote scheduled, House Republican leaders worked Tuesday to win votes one at a time for their latest bill to repeal the Affordable Care Act after an influential Republican voice on health care came out against the measure.
A failure to get the repeal bill to a vote this week would be the third time that Speaker Paul D. Ryan could not rally his considerable House majority around a legislative priority that Republicans have promised for seven years.
Republican leaders were ready to move on from health care after the embarrassing collapse of their measure in March, but President Donald Trump pressed Ryan hard to deliver on a major campaign promise and personally pressured House members to fall into line.
If the effort fails, it will greatly weaken the president's hand on Capitol Hill and cast a shadow across the rest of his legislative agenda, especially the deep tax cuts and rewrite of the tax code that he has proposed – and that are likely to be no easier than health care.
Rep. Fred Upton of Michigan was only the latest Republican defector, but he carries more sway than most. The former chairman of one of the House committees that drafted the American Health Care Act, as the Republicans call their measure, Upton said the latest version of the health care bill "torpedoes" protections for people with pre-existing medical conditions.
Upton, who led the House Energy and Commerce Committee as the repeal movement built steam, declared on a local radio show, "I cannot support this bill with this provision in it," just as Ryan was insisting that the legislation would protect the sick.
The loss of Upton, who has served in the House for 30 years, was a huge blow to Republicans, who had hoped to get the bill through the House by Thursday, before lawmakers go home again and face pressure from constituents. The Upton decision, which could give other Republicans cover to defect, came as party leaders faced an onslaught of advocacy groups saying the bill would harm the nation's most vulnerable citizens – and as a late-night talk show host, Jimmy Kimmel, made an emotional appeal.
A tearful Kimmel on Monday night told the story of his infant son, Billy, who was born with heart defects and underwent surgery. Kimmel pleaded with Congress not to undermine the Affordable Care Act's ban on discrimination against people with pre-existing conditions.
After Kimmel's monologue went viral, former President Barack Obama weighed in on Twitter, writing: "Well said, Jimmy. That's exactly why we fought so hard for the ACA, and why we need to protect it for kids like Billy."
House Republican leaders are also fighting against the clock. The House is scheduled to be in recess beginning on Friday and is not set to return until May 16. Republicans who are on the fence are likely to get an earful from their constituents.
"I think it's imperative that we have a vote before we leave for a week," said Rep. Mark Meadows, R-N.C., the chairman of the conservative House Freedom Caucus.
In the radio interview, Upton was explicit: Concessions made to win over the hard-line members of the Freedom Caucus were costing the leadership support from more moderate Republicans. He said "there are a good number of us that have raised real red flags and concerns."
"We want to make sure that those with pre-existing illness – whether it be cancer or lupus or diabetes – they are not going to be discriminated against with a lot higher premiums," Upton said.
Trump, whose advisers have been pressing aggressively for a vote on the health care overhaul, seemed oblivious of the latest setback for the measure on Tuesday.
"How's health care coming folks, how's it doing – all right?" Trump said, addressing Republican lawmakers attending a trophy award ceremony in the White House Rose Garden for the United States Air Force Academy's football team. "We're moving along? I think it's time now, right?"
After visiting the Capitol on Monday, Vice President Mike Pence returned Tuesday, trying to corral votes for the repeal bill. Ryan insisted that Republicans were "making very good progress with our members," but he offered no indication of when a vote might be held.
Republicans were clearly divided over the adequacy of the bill's protections for people who are sick or disabled.
"There are a few layers of protections for pre-existing conditions in this bill," Ryan said.
At the heart of the debate is an amendment to the repeal bill proposed by Rep. Tom MacArthur, R-N.J. The amendment, which won over the Freedom Caucus last week, would give state governments the ability to apply for waivers from the existing law's required "essential health benefits," such as maternity, mental health and emergency care, and from rules that generally mandate the same insurance rates for people of the same age, regardless of their medical conditions.
With a waiver, states could permit insurers to charge higher premiums based on the "health status" of a person who had experienced a gap in coverage. To qualify for a waiver, a state would have to have an alternative mechanism, like a high-risk pool or a reinsurance program, to provide or subsidize coverage for people with serious illnesses.
"States can't leave people with pre-existing conditions high and dry," MacArthur said Tuesday, defending his proposal.
But the MacArthur amendment has distressed some Republicans because of concerns that it would allow states to gut protections for consumers.
Rep. Tom Rooney, R-Fla., said he was "leaning yes" on the repeal bill, but agonizing over how to explain his vote to constituents.
"I have a lot of people who call my office on a daily basis who are extremely angry," he said. "It's not just because I'm a Republican, but because they are sincerely scared."
Many people with pre-existing conditions fear that they may lose coverage and "are going to die because of a vote we might be taking," Rooney said.
The Freedom Caucus had pushed hard to roll back federal insurance requirements.
"The pre-existing condition debate and discussion in Congress, far as I'm concerned, is over," Rep. Scott Perry, R-Pa., a member of the Freedom Caucus, said Tuesday. "They are covered; we acknowledge it; we provide for it; it is done."
The White House threw a hand grenade into the delicate negotiations over health care Tuesday when Trump's budget director, Mick Mulvaney, suggested the administration might take action that would undermine the Affordable Care Act, with or without Congress.
Mulvaney raised doubts about whether the federal government would continue making certain payments to insurers. The payments enable insurers to reduce deductibles and other out-of-pocket costs for low-income people, a form of assistance known as cost-sharing reductions.
Discussing a bipartisan agreement in Congress to fund the federal government for the next five months, Mulvaney said, "There's absolutely no language in this bill that requires us to make any Obamacare bailout payments, any CSR payments of any way, shape or form as a result of this deal, OK?"
Asked directly whether the Trump administration would provide the money for this month, he said, "We've not made any decision."
The White House Office of Management and Budget later said Mulvaney meant to say that the administration had made no commitment to pay the subsidies beyond May.
The House Democratic whip, Steny H. Hoyer of Maryland, said Mulvaney's comments undermined confidence in insurance marketplaces and would "force premiums to skyrocket, hurting consumers."
Congress' inability to agree on health care legislation is already sending tremors through insurance markets, making it much more difficult for insurers to plan for 2018.
Monday was the deadline for insurers in California to file preliminary information on rates and benefits for next year. Dave Jones, the California insurance commissioner, said he had taken "the unprecedented step of authorizing health insurers to file more than one set of proposed rates for 2018 – one assuming the ACA is enforced and funded, and the other assuming that Trump and House Republican leaders continue to undermine or repeal the law and cause unnecessary premium increases."
Even as some Republicans have come out in opposition to the repeal bill in recent days, the Trump administration and House Republican leaders have also picked up support from other party members.
Rep. Paul Gosar, R-Ariz., said Tuesday that he had switched to yes after receiving assurances that the Senate would vote on one of his bills, which would scale back the federal antitrust exemption for health insurance companies.