WASHINGTON — The House Freedom Caucus, a group of hard-line conservatives who were instrumental in blocking President Donald Trump’s plan to repeal the Affordable Care Act last month, gave its approval Wednesday to a new, more conservative version, breathing new life into Republican efforts to replace President Barack Obama’s health law.
Senior White House officials, led by Reince Priebus, the chief of staff, have relentlessly pressed Republicans to revive the health care push before Trump’s hundred-day mark on Saturday, and with conservatives falling into line, the bill has a chance to get through the House, possibly as early as Friday.
It was not clear whether conservative support for the revised legislation would be matched by losses in the center, especially among Republicans representing districts won by Hillary Clinton. But the rest of the House Republican Conference was left with a stark choice: Reject the measure and take the blame previously left at the feet of conservatives for undermining a central goal of the administration, or give it the nod, please voters who want a repeal, and risk taking a potentially fatal hit in the next election for approving a measure expected to leave tens of millions of Americans without insurance.
“Members went home and got an earful,” said Rep. Tom Cole, R-Okla., saying that voters were wondering, “Why can’t you get something done?” Cole said he was now “cautiously optimistic” that the measure could pass on the floor.
The latest proposal, drafted by Rep. Tom MacArthur, R-N.J., a moderate, would allow states to obtain waivers from federal mandates that insurers cover certain “essential health benefits,” like emergency services, maternity care, and mental health and substance abuse services, which many Republicans argue have driven up premiums.
It also would permit states to waive requirements that insurers charge the same rates for people the same age, essentially ending the current ban on rejecting coverage for pre-existing conditions if state governments establish high-risk pools where sick people can purchase health care.
To qualify for a waiver, a state would have to explain how it would advance at least one of five purposes: reducing average premiums for consumers; increasing the number of people with coverage; stabilizing the insurance market; increasing the choice of health plans; or stabilizing premiums for people with pre-existing conditions.
The House Freedom Caucus members, acutely aware that the White House and Republican colleagues blamed them for the failure of the earlier bill, were eager to shift the blame to more moderate members who may now reject the measure. And the biggest conservative pressure groups off Capitol Hill — Heritage Action, Club for Growth and Freedom Partners — dropped their opposition to the measure, known as the American Health Care Act.
“Over the past couple of months, House conservatives have worked tirelessly to improve the American Health Care Act to make it better for the American people,” Alyssa Farah, a spokeswoman for the House Freedom Caucus, said in a prepared statement. Because of those changes, she added, “the House Freedom Caucus has taken an official position in support of the current proposal.”
The group agrees to take an official position when 80 percent of their roughly three dozen members agree.
But what is good for the most conservative corners of the House is not necessarily going to please their colleagues, including the dozens who had already rejected a less-conservative version of the bill. Republican senators had been equally wary. “I think a better approach is to stabilize the insurance pool,” said Sen. Bill Cassidy, R-La.
In effect, the more that the bill changes to get through the House, the less chance it has of surviving in the Senate, both because of Senate rules and because the provisions that conservatives have excised are popular.
A recent ABC News/Washington Post poll found that 62 percent of respondents supported nationwide minimum insurance coverage standards and just 33 percent would leave such standards up to the states. Among Republicans, 54 percent supported a nationwide standard for coverage of pre-existing conditions.
Republican senators from states that have expanded Medicaid under the Affordable Care Act said the new House bill did nothing to ease their concerns about the deep cuts to Medicaid that remain in the legislation.
“There’s still going to be some of us here in the Senate who would like to weigh in, particularly on Medicaid expansion, which is not part of the bill,” said Sen. Rob Portman, R-Ohio.
Democrats assailed the latest proposal, saying it did nothing to help the 24 million people who, according to the nonpartisan Congressional Budget Office, would lose coverage by 2026 under the repeal bill.
They denounced one part of the new proposal that, they said, would protect health insurance for members of Congress. This provision, they said, guarantees that lawmakers would not lose “essential health benefits” and could not be charged higher premiums because of their health status. The group that helps elect House Democrats immediately unleashed internet ads in 30 Republican-held districts railing against the carve out. A Democratic interest group, Priorities USA, followed suit.
“The monstrous immorality of Trumpcare is perfectly encapsulated in House Republicans’ plan to exempt their own health coverage from the damage it will do to everyone else,” said the House Democratic leader, Nancy Pelosi of California.
Trump, seeking a major legislative victory in the first 100 days of his presidency, has been pressing hard to get a floor vote on a measure to repeal Obama’s signature health care law and to fulfill a campaign promise of most Republicans for the better part of a decade.
Vice President Mike Pence and other White House staff have been feverishly trying to get the most conservative members to support a bill, even one that is not viable in the Senate, and without the input of many moderate members.
But the effort may be creating momentum.
“The key is, all of us recognize we and the president made campaign promises to repeal and replace Obamacare,” said Rep. Chris Collins, R-N.Y., a top Trump ally. “We, as a team, all recognize we need to get to yes.” He added: “I am guardedly optimistic.”
Speaker Paul Ryan said Wednesday that a new bill could come to the floor at some point if sufficient support surfaced. “We’ll vote on it when we get the votes,” he said.
As Republican leaders maneuvered toward a vote to repeal the Affordable Care Act, they were also working to assure Democrats that the government would continue to subsidize out-of-pocket expenses for customers purchasing insurance through the law’s online marketplaces. Democrats have threatened to hold up legislation to keep the government funded past Friday unless they get guarantees that the so-called cost-sharing reductions would continue.
House Republicans had successfully sued the Obama administration to stop the payments, arguing that the administration was illegally spending money that Congress had not explicitly appropriated. By Wednesday afternoon, Democrats appeared convinced that the money would keep flowing, a significant promise that should reassure insurance companies as they decide whether to offer policies on the marketplaces in 2018.
Pelosi neared a declaration of victory on that front, and on efforts to block funding this year for Trump’s promised wall on the Mexican border.
“Our major concerns in these negotiations have been about funding for the wall and uncertainty about the CSR payments crucial to the stability of the marketplaces under the Affordable Care Act,” she said. “We’ve now made progress on both of these fronts.”
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