Republicans cleared a path Thursday for their Obamacare replacement to reach the House floor, pushing a bill through the Budget Committee on a tight vote that saw the first GOP defections.
The committee was stitching together plans from two other panels, and now has produced a unified bill — though Republican leaders say they’re still pondering changes designed to win over conservatives who fear the replacement bill is too expensive and too much like Obamacare.
“Don’t cut off the discussion,” said Budget Committee Chairman Diane Black, Tennessee Republican, as she cajoled the bill through on a 19-17 vote.
Three Republicans from the vocal House Freedom Caucus — Reps. Dave Brat of Virginia, Gary J. Palmer of Alabama and Mark Sanford of South Carolina — joined every Democrat in opposing the package.
The Congressional Budget Office estimated the plan would result in 24 million fewer people holding insurance a decade from now, spooking centrist members, while conservatives said an estimated $300 billion in net spending cuts isn’t enough to win their support for a new entitlement.
“Most people are opposed to the bill, and it’s interesting, because it’s from both the right and the left,” Rep. Raul R. Labrador, Idaho Republican, said at a Conversations with Conservatives event hosted by The Heritage Foundation. “There’s no natural constituency for this bill, which is one of the most frustrating things about this bill. We’re trying to figure out who, exactly, it’s trying to appease.”
Mr. Labrador and the rest of the Freedom Caucus say the GOP plan falls short because it doesn’t outright repeal the Affordable Care Act, nor does it cut insurance premiums enough.
They said they are drafting an amendment that would make the bill acceptable to their members, but refused to share details with reporters.
Whatever they propose, however, could scare off centrist votes, who say the bill is already too draconian.
House Speaker Paul D. Ryan waved aside complaints that the process is messy, saying “this is legislating,” and he praised President Trump for staying engaged.
“He is helping bridge gaps in our conference,” Mr. Ryan said. “He is a constructive force to help us get to a resolution so that we get consensus on how to repeal and replace Obamacare. It’s been very helpful.”
Getting the bill through the House is just the first step. It then must pass a Senate where conservatives and moderates are also at odds, and which has even less margin for error as Republicans hold only a 52-48 majority.
In six hours of debate Thursday, the Budget Committee defeated Democratic motions to ensure that no one would lose coverage under the plan and attempts to remove a portion of the bill that would defund Planned Parenthood over its abortion practice.
Republicans, meanwhile, pushed provisions that would allow states to run their Medicaid programs as they see fit, while requiring able-bodied enrollees to work in exchange for benefits.
More changes could come next week when the bill makes a stop at the Rules Committee, before reaching the floor.
Members of the Republican Study Committee, an influential bloc of conservatives, said they are working to add a work requirement for some Medicaid beneficiaries, and want to freeze President Obama’s expansion of the program in 2018 rather than 2020.
That last change is a “nonstarter” for centrist Republicans who call themselves the Tuesday Group.
The current plan repeals most of Obamacare’s taxes and its unpopular mandate requiring people to hold insurance. It replaces Obamacare’s subsidies with refundable, age-based tax credits, while allowing insurers to charge older Americans up to five times what they charge young people, instead of Obamacare’s 3-to-1 ratio.
It also reins in and caps federal spending on Medicaid — an overhaul that would cut spending by nearly $900 billion and nudge 14 million out of the program by 2026, according to CBO estimates.
“Let’s be clear about who would lose that coverage and care: It’s parents struggling to get by on poverty-level wages, seniors in nursing homes, children and people who are too disabled to work,” said Rep. John A. Yarmuth, Kentucky Democrat. “So let’s be honest: This is not a health care bill, it is an ideological document. A fantasy about ‘freedom’ and ‘choice’ in a market that doesn’t exist.”
Republican leaders say they wanted to go even further in the bill, but the reconciliation process constrains what they can do legislatively on the first try, so members should look forward to additional phases of reform.
Step two would involve regulatory changes, and step three would involve more legislation that would have to face an expected Democrat-led filibuster in the Senate.
Some Senate Republicans said the House should slow down and develop a plan with broad party appeal since Democrats will never help Republicans with reforms that are supposed to come in the third phase and will require 60 votes.
For now, it’s Mr. Ryan’s fight to win, as House conservatives demand changes.
“I think we’re going to move on, we’re going to end up finding a way to get this done, and we’re going to move onto something else that will be the crisis of the day,” Rep. Mark Meadows, North Carolina Republican and chairman of the Freedom Caucus, told reporters. “At this particular point, I think it’s incumbent upon us to realize that we have one boss, and that boss is back home, for me, in North Carolina.”