At Trump's request, House may tweak health-care bill before recess

PHOTOGRAPHER: The New York Times

“Repeal Obamacare” buttons at a Heritage Foundation booth during the Conservative Political Action Conference on Feb. 23, 2017.

WASHINGTON – House Republican leaders are planning to modify their stalled health-care bill Thursday after Vice President Mike Pence pressured them to show progress toward passing the bill before lawmakers leave for a two-week recess.

An amendment providing for “high-risk pools” – a mechanism to subsidize pricier insurance coverage for the seriously ill – is set to be added to the health-care bill at a Rules Committee meeting Thursday. But while leaders said the tweak showed momentum for the legislation, it appeared that larger divisions over the bill’s content have yet to be bridged.

On Thursday morning, House Speaker Paul D. Ryan, R-Wis., invited more than 20 fellow Republicans to his weekly news conference to unveil the new amendment in what appeared to be an effort to show progress toward an accord.

“This brings us closer to the final agreement that we all want to achieve,” Ryan said, later adding that it was “a step in the right direction.”

The amendment before the Rules Committee would set up a federal insurance pool for those with serious and expensive medical conditions such as cancer, congestive heart failure and HIV/AIDS. The fund is intended to subsidize coverage for patients with those serious preexisting conditions to lower premiums for healthier patients.

Committee Chairman Kevin Brady, R-Texas, said the amendment, sponsored by conservative Reps. Gary Palmer, R-Ala., and David Schweikert, R-Ariz., demonstrates “another example of House Republicans’ unwavering commitment to repeal and replace Obamacare and provide immediate relief to those trapped in this failing law.”

Pence made his request to Ryan and Majority Leader Kevin McCarthy, R-Calif., during a Wednesday evening visit to the White House, according to several individuals briefed on the meeting. These individuals asked for anonymity in order to discuss private conversations.

According to a senior White House official not authorized to speak publicly, Pence conveyed in the intense discussion that the president wanted the House to move immediately on health care in order to keep the effort to repeal the 2010 Affordable Care Act alive. President Trump needs to score a short-term win on the issue, the vice president emphasized, since otherwise lawmakers may retreat.

A House aide said Pence and other White House officials painted a “dire” political picture of what would happen if Republicans fail to act on health care. Ryan also met briefly with Trump, the aide said.

But GOP leaders have yet to demonstrate that this amendment alone will resolve the differences between moderates and conservatives that scuttled their initial health-care proposal late last month.

Rep. Raúl R. Labrador, R-Idaho, one of the Freedom Caucus’s most outspoken members, called it a “good” amendment but said he’s “not yet” ready to sign on to the underlying measure.

“They’re moving in the right direction,” he said. “We’re still working on it.”

Rep. Tom MacArthur, R-N.J., a co-chairman of the moderate Tuesday Group and a key player in the intraparty negotiations, praised the idea behind the amendment and said it simply reflected lawmakers’ ongoing policy work. Still, he would not say if he backs the measure,, which provides $15 billion in federal subsidies for those in the high-risk pool.

“Nobody was grasping for an idea to go home with,” MacArthur told reporters. “The reality is we’re still needing to find an ultimate conclusion before we can vote on this bill, and we’re not there yet obviously.”

McCarthy and Majority Whip Steve Scalise, R-La., said talks would continue through the recess and did not rule out possibly returning lawmakers to Washington early if a compromise comes together.

Huge roadblocks remain in the way of such a deal. At a Politico event Thursday morning, the chairman of the hard-right House Freedom Caucus laid out a path to get “the majority if not the entire Freedom Caucus” to vote for the bill – by extending the ability for states to apply to waivers to key ACA insurance mandates. But there appears to be little appetite for doing that elsewhere in the House GOP.

Rep. Patrick T. McHenry, R-N.C., said Wednesday that rolling back those mandates – intended to protect insurance access for people with preexisting medical conditions – would be a nonstarter: “It goes counter to the president’s promises. It goes counter to the promises of more than 200 members of the House.”

High-risk pools, such as the amendment proposes, have long been a staple of conservative health-care reform plans, allowing insurers to rope off patients with exponentially higher costs from the rest of the population they insure. To fund the high-risk pools under their bill, House Republicans have proposed providing states more than $100 billion in federal “stabilization” funds.

But some high-risk pools operating before passage of the ACA were not financially viable and Avalere Health President Dan Mendelson warned the same thing could happen again, given this group’s extremely high medical expenses.

“The amount that they’ve allocated seems really big,” Mendelson said, referring to House leaders, “until you realize these are the train wrecks.”

The 2010 law created a temporary high-risk pool, called the Pre-Existing Condition Insurance Plan (PCIP), which operated from mid-2010 until Dec. 31, 2013 and received $5 billion to help cover consumers’ costs.

While the law also allowed insurers to waive several federal mandates for this pool of customers – such as free preventive care services, the same premium charges for men and women – a December 2014 analysis by the Commonwealth Fund concluded that “coverage was still very expensive for both enrollees and administrators.”

Hoover Institution research fellow Lanhee Chen, a health care policy expert who has advised both GOP 2012 presidential nominee Mitt Romney and Sen. Marco Rubio, R-Fla., said in a recent interview that while high-risk pools have encountered problems in the past that could be addressed through sufficient federal subsidies.

He estimated that “somewhere in the $10 billion to $20 billion ballpark” each year would likely be enough.

Some House members – though not all – see the provision as a companion to potentially allowing states to opt out of the ACA’s ban on charging those patients higher premiums, known as “community rating,” as well as its requirement for insurers to sell policies to all who wish to buy them, known as “guaranteed issue.”

That issue has become one of the key sticking points in House Republicans’ ongoing clashes over how to repeal and replace the ACA. Rep. Mark Meadows, R-N.C., the Freedom Caucus chairman, said Thursday that allowing states to roll back community rating, guaranteed issue and a litany of policy benefit mandates would win his group’s votes, but moderates say they’re important protections for patients.

High-risk pools, however, had gained broad support during a late Tuesday meeting on Capitol Hill that brought together Pence and other White House officials with conservative and moderate House leaders.

Thursday’s action appeared to be a move rooted more in politics than in policy, sparking a partisan fight at the Rules Committee Thursday.

Rep. Pete Sessions, R-Texas, the panel’s chairman, said the addition of the amendment was intended to “lock in ideas so that we now have several weeks to go home and to further amplify” to constituents why the broader health-care bill is good.

“Members can go back home and say, ‘Thank you for the feedback,'” he said.

Rep. Jim McGovern, D-Mass., a Rules Committee member, said the amendment was poorly vetted and would only worsen the GOP bill’s impacts.

“Will Rogers once said, ‘If you find yourself in a hole, stop digging,’ and you guys are digging a damn trench here,” he said. “You keep on going into backrooms and coming out with amendments that might solve some of your political problems, but they do nothing to help the millions of Americans who will lose insurance thanks to your bill.”

Several White House officials said they were pleased the House was moving ahead with the amendment. But one senior aide to the president, who asked for anonymity to speak frankly, added that the White House wants to get the health care rewrite done “correctly,” not necessarily “quickly.”

The White House meeting Ryan and McCarthy attended took place in Chief of Staff Reince Priebus’s office. Along with Pence, they met with a slew of the president’s top aides, including budget director Mick Mulvaney, chief strategist Stephen K. Bannon and Domestic Policy Council Director Andrew Bremberg.

Priebus – who as Republican National Committee chairman developed close ties to Ryan and other congressional leaders – also pressed for action, one White House official said. Bannon has echoed these calls for action and was one of the most vocal players in pushing for a contentious floor vote in the hours before the legislation was initially shelved, believing that only a “foot on the throat” of House Republicans would get them to fall in line, according to one person close to Bannon.

But even as work on the House bill intensified, many Senate Republicans, remain leery of efforts to shift the party debate on health-care policy to the right.

While White House officials have also discussed in the past week whether an eventual compromise with Democrats could be possible, according to one individual who asked for anonymity in order to speak frankly, there is no evidence that Trump and his aides are pursuing that path.

Until the meeting, there was no indication that there would be a formal effort to tweak the bill before lawmakers left Washington.

There may be no immediate independent estimate of the fiscal and coverage impacts the amendment might have. According to a person with knowledge of discussions at a Ways and Means staff meeting Thursday morning, House Republicans don’t plan to get a score from the Congressional Budget Office estimating how much a federal high-risk pool would lower premiums unless they are first assured there are enough votes to pass it,

The $15 billion to pay for the federal pool would come out of the GOP health care bill’s deficit reduction, reducing the measure’s savings from $150 billion to $135 billion. Staff also said the firm Milliman is expected to release a study Thursday or Friday speaking to some parts of the proposed health-care plan.

The Washington Post’s Robert Costa, Abby Phillip and Paul Kane contributed to this report.