Divisions sharpened last week between hard-right and more pragmatic Republicans over both policy and strategy for repealing and replacing the Affordable Care Act.
Those differences—along with the apparently slow progress in drafting actual legislation that could be scored by the Congressional Budget Office on cost and coverage impact—underscore the tough struggle Republicans face in dismantling Obamacare and establishing an alternative system.
One of their biggest disagreements is over the future of the ACA's expansion of Medicaid coverage to more than 10 million low-income adults. Conservatives want to eliminate it while a number of GOP senators and governors want to keep that coverage.
Congressional Republicans are feeling growing pressure to show progress on healthcare. Many are going back to their districts this week and holding town hall events, where they may face constituents who are upset about the potential loss of their ACA coverage. In addition, insurers are signaling they may pull out of the individual market in 2018, as Humana announced it would do last week.
House Speaker Paul Ryan promised Thursday to introduce repeal-and-replace legislation when the House returns from recess on Feb. 27, though he's presented no legislative language so far. He said he's waiting for the CBO and the Joint Committee on Taxation to score his proposed bill on costs and coverage levels before it's unveiled.
Ryan has promised the House will repeal most of the ACA via an expedited budget reconciliation bill passed on a party-line vote by early April. He's indicated it will include some replacement features, such as expanded health savings accounts and age-based premium tax credits.
GOP leaders want to erase most of the ACA taxes that fund the law's coverage expansions and replace them with a cap on the tax exclusion employees receive for employer-provided health benefits.
Two people familiar with Ryan's proposal told the Associated Press that employees would pay taxes on the value of coverage above $12,000 for individuals and $30,000 for families. Republicans would not confirm those amounts. But House Ways and Means Committee Chairman Kevin Brady told reporters that the “vast majority of Americans” would be unaffected. That suggests it wouldn't raise much revenue.
That proposal is likely to trigger strong opposition from business and labor groups and from many conservative congressional Republicans, who may see it as a new tax.
“You have to legislate with a sense of political reality,” said Republican Rep. Tom Cole of Oklahoma. Backing a tax proposal would hurt lawmakers in the 2018 elections because it “would set up an ad against you from multiple directions.”
The day before Ryan's announcement, leaders of the very conservative House Freedom Caucus, joined by Sen. Rand Paul of Kentucky, demanded that Republicans quickly repass their 2016 budget reconciliation bill to repeal most of the ACA, without worrying about replacement provisions.
They touted Paul's Obamacare Replacement Act, a bill that almost certainly would leave millions of people currently covered under the ACA uninsured, as their alternative. Rep. Mark Sanford of South Carolina has introduced a companion bill in the House.
The 2016 repeal bill would erase federal funding for the Medicaid expansion after two years. Asked whether the nearly 40 House Freedom Caucus members would work with Senate Republicans on maintaining some form of Medicaid coverage for those who have received it, Rep. Mark Meadows, the caucus chairman, ruled that out. He said his members want to repeal the expansion entirely and offer health savings accounts to help that low-income population.