Wavering Pa., N.J. Republicans push for changes in Obamacare repeal

WASHINGTON — As Vice President Pence and House Speaker Paul Ryan try to muscle their Affordable Care Act repeal bill over the finish line — and appear perilously close to losing the necessary votes — Republicans from the Philadelphia area are seeking changes to help get them to yes.

GOP congressmen from the centrist Tuesday Group, led by Reps. Tom MacArthur of South Jersey and Charlie Dent of Allentown, this week pushed for more generous tax credits in Ryan's replacement plan. They also argued in public and private against a conservative initiative to speed up proposed cuts to Medicaid as they work to roll back Obamacare.

"That's what I'm working on with other members of the Tuesday Group and trying to get to a place where we can be a yes," said MacArthur, who co-chairs the caucus along with Dent.

At stake are the contours of a bill that could again reshape the country's health care system, ending subsidies and some insurance mandates imposed by President Barack Obama's health law, and replacing them with tax credits and looser rules on the insurance market. Gone would be federal support that has helped about 20 million people obtain health insurance since 2010. In its place could be a bill that offers less help to the poor and elderly, who are projected to face far higher costs, and also fewer government requirements.

About 24 million fewer people would have insurance in a decade compared with what would happen under the current law, according to an estimate by the nonpartisan Congressional Budget Office, but the federal budget deficit would fall and, Republicans argue, the government would have a smaller hand in health care.

Many local Republicans support the idea of rolling back the Affordable Care Act, but have raised concern about the details, particularly the costs on older Americans.

They also worry about the impact on their constituents. More than one million people in Pennsylvania and New Jersey have gained health insurance from the original law's Medicaid expansion, and both states rely on federal aid to help pay for their coverage. The GOP plan, as proposed, could limit new enrollment and impose higher costs on the states starting in 2020. Local Republicans say the changes should come no sooner — but conservatives are pushing to make the shift as soon as next year.

On Friday, Gov. Wolf's administration told Pennsylvania's congressional delegation that the proposed Medicaid cuts would require the state to find $2.2 billion to cover the people included in the expansion, "a cost we simply cannot absorb without devastating cuts to other critical program," the governor said in a statement.

Tuesday Group members laid out their case in a meeting with Pence on Wednesday, and Dent and MacArthur pushed their tax-credit proposal in a smaller breakfast Thursday with Ryan and House conservative leaders. Still, it's unclear whether their proposals will be accepted, and many local Republicans remain noncommittal ahead of a full House vote as soon as next week.

With both conservatives and moderates balking at pieces of the bill, it's not clear if GOP leaders have the votes to pass their plan, and they are being pulled in opposite directions. Changes sought by the moderate bloc could alienate conservatives, while moving to the right could cost them centrists from the Philadelphia region. With Democrats uniformly opposed to the Ryan bill, Republicans can afford only 21 House defections — and have even less margin in the Senate.

Many Republicans are beginning to voice concerns about casting a vote in the House for a measure that ends up dead in the Senate.

"This bill needs to be improved," MacArthur said Thursday — though he stopped short of saying he would vote against the current legislation. "I'm not prepared to put a line in the sand, but this bill cannot move forward the way it is."

A day earlier, Dent said he had "serious concerns and reservations about the bill in its current form."

Several other Republicans from the area, including Reps. Frank LoBiondo (R., N.J.), Ryan Costello (R., Pa.), and Patrick Meehan (R., Pa.), have also voiced concerns — though it's unclear how many of them, or any of the 54 Tuesday Group members, would ultimately oppose a central GOP priority if they don't get their way.

Costello and Meehan have already voted for the plan in their House committees, but have since raised worries based on the Congressional Budget Office analysis of the measure's likely impact.

"The points that [Dent] raised loom very large for me too, with Medicaid, with the tax credits, and how this all comes together, especially the situation with seniors," LoBiondo said. "They're promising that they can fix some of this, but that's what I'm waiting to see."

The moderate group is asking Ryan to increase proposed tax credits to help offset CBO projections showing steep cost increases for low-income and older consumers. MacArthur would not reveal details of his proposal, but said he hopes the tax credits would come close to matching what those Americans now receive in insurance subsidies.

And, MacArthur argued, the tax credits would give recipients more flexibility. They could use the full amount to help pay for health insurance, or use only some of it for insurance and put the rest in a Health Savings Account for deductibles or other medical expenses.

But boosting those credits could chafe conservatives, many of whom have objected to the level of credits already included in the bill. More generous aid would also eat into one of the bill's key selling points — a projected $337 billion deficit reduction over a decade.

"This is a health-care reform bill, not a deficit reduction bill," MacArthur said. "The fact that we get some savings on the deficit is great, but I think we should reinvest some of that to make sure that Americans have a smooth transition to a new system of health-care delivery."

He said he and others centrists were open to considering some ideas pushed by conservatives, including adding a work requirement to the Medicaid provisions. President Trump reportedly agreed to that idea in a meeting Friday with one conservative bloc, the Republican Study Committee, though the most vocal group on the right, the Freedom Caucus, remained unconvinced that the bill goes far enough to erase the existing health law.

That group wants to implement cuts to Medicaid as soon as next year, rather than 2020.

Both Dent and LoBiondo said speeding up the Medicaid rollback would be "a nonstarter." Costello has also opposed the move and MacArthur said, "That date to me is sacrosanct."

A test of where the bill ends up, and how local Republicans react, could arrive as soon as next week. A full House vote is expected Thursday.