Trump struggles to win all sides on health bill

WASHINGTON—President Donald J. Trump’s push this week to revive legislation to repeal the Affordable Care Act (ACA) by placating the most conservative House members risks alienating more moderate Republicans, whose votes he needs just as much, and Republican leaders cautioned on Tuesday that no action was imminent.

Vice President Mike Pence was meeting continually with House Republicans on Monday and Tuesday to rework and resuscitate the repeal bill that collapsed on the House floor on March 24. But the House speaker, Paul D. Ryan, acknowledged that changes considered to gain support on one side of the House Republican Conference could lose votes on another. “It’s important that we don’t just win the votes of one caucus or one group, but that we get the votes and the consensus of 216 of our members,” Ryan said.

In negotiations with members of the conservative House Freedom Caucus, administration officials discussed allowing states to opt out of two bedrock requirements in the ACA.

One requires insurers to cover a standard minimum package of benefits, known as essential health benefits. The other generally requires insurers to charge the same price to people of the same age who live in the same geographic area, with a possible surcharge for tobacco users.

Under this provision, known as community rating, insurers cannot vary premiums based on a person’s health status, insurance claims history or gender. Rep. Mark Meadows, Republican-North Carolina, the chairman of the Freedom Caucus, said he was pleased that the administration was willing to eliminate more of the mandates in the ACA, which Republicans have been trying to repeal ever since it was signed by President Barack Obama in 2010.

“Lower premiums have to be our first and only priority,” Meadows said on Tuesday. “By repealing community rating and the essential health benefits, it allows for lower premiums across the board.”

But Meadows said Freedom Caucus members wanted to see the language that would be added to the repeal bill before promising to vote for it.

At the same time, more moderate Republicans were expressing concern for other reasons. Administration officials say they want to preserve one of the most popular provisions of the ACA, which bars insurers from denying coverage to people with pre-existing medical conditions. But without a requirement for some form of community rating, insurers could effectively do that, simply by increasing the cost of policies for sick or risky customers.

“I don’t think we will have something that eliminates community rating,’’ said Rep. Tim Murphy of Pennsylvania, a member of the caucus of moderate Republicans known as the Tuesday Group. “That just can’t be.”

Murphy, a psychologist, has successfully championed legislation to improve treatment for mental illness and drug abuse, including opioid addiction. He said he wanted to be sure that any changes to the bill protected mental-health care and treatment for substance abuse disorders, as well as maternity care—benefits that are guaranteed under the ACA.

Ryan and the White House each tried to play down expectations of a breakthrough, saying the talks on a new healthcare bill were at a preliminary, conceptual stage.

Sean Spicer, the White House press secretary, said the vice president and the chief of staff, Reince Priebus, were “very optimistic” about the possibility of developing a health-care bill that could win a majority of votes in the House.

“The president would like to see this done,” Spicer said. “If we can get a deal and it gets to those votes—which, again, I’m not going to raise expectations, but there are more and more people coming to the table with more and more ideas about how to grow that vote.”

New York adopted community rating under a state law in the 1990s, and the policy caused serious problems in the individual insurance market, but state officials have come to accept it.

Rep. Tom Reed, Republican-New York, who supported the original version of the repeal bill last month, said on Tuesday: “Community rating is one of those things that is a very significant reform in the Affordable Care Act. I appreciate the states’ rights argument but recognize that there is a reason behind community rating and the benefit that it brings to the insurance reforms.”

Democrats say that relaxing federal standards for benefits and rates would, in effect, eviscerate protections for people with preexisting conditions.

Some Republicans appear to share that concern. Allowing states to opt out of the federal requirements for minimum benefits and community rating “could greatly erode the safeguards Obamacare put in place for those with preexisting conditions”, said Rep. Leonard Lance, Republican-New Jersey, who opposed the earlier House-repeal bill and has not moved from that position.

Rep. Chris Collins of New York, a Trump ally and member of the Tuesday Group, said he too was concerned about allowing states to obtain waivers from the community-rating requirement.

“It’s one thing if you have car crashes and you pay higher car insurance,” Collins said. “Health is a different animal. If you have high-blood pressure or high cholesterol, it might beg the question, what if you are on a medication and it’s currently under control? I don’t know what all that would mean.”

The version of the repeal bill that went to the House floor last month died after Republican leaders, in a bid for conservative support, agreed to eliminate federal standards for minimum benefits. Under the proposal now under consideration, states could obtain waivers from the federal requirements.

“States can often do a better job, usually do a better job, of understanding the needs of their residents and creating health care plans that help those residents, more than the federal government can,” said Rep. Tom MacArthur of New Jersey, a chairman of the Tuesday Group. “The whole current system is a one-size-fits-all, applying everywhere.”

New York Times News Service


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