01/27/us/politics/affordable- care-act-republican-retreat. html?emc=edit_th_20170128&nl= todaysheadlines&nlid=2318049&_ r=0
WASHINGTON — Congressional Republicans, meeting behind closed doors this week in Philadelphia, expressed grave concerns about dismantling the Affordable Care Act on the urgent timetable demanded by President Trump, fretting that, among other things, they could wreck insurance markets and be saddled with a politically disastrous "Trumpcare."
An audio recording of a session at their annual retreat, obtained by The New York Times, shows Republicans in disarray, far from agreement on health policy, and still searching for something to replace former President Barack Obama's health care law. While their leaders called for swift action to rescue consumers from the Affordable Care Act, some backbench Republicans worried about potential pitfalls.
"We had better be sure that we are prepared to live with the market being created," said Representative Tom McClintock of California, because "that's going to be called Trumpcare."
He added, "Republicans will own it lock, stock and barrel, and we'll be judged on that."
When Democrats were writing the Affordable Care Act seven years ago, their primary goal was to provide health insurance to more people, an ambition that the Obama administration went to great lengths to fulfill as it enrolled millions of people in Medicaid or private health plans.
Now, as Republicans try to devise a replacement for the law, they have set a nearly impossible standard for themselves: They have promised that none of the 20 million people who gained coverage through the Affordable Care Act will lose it if the law is repealed, even as they lift its mandates and penalties, pull back the tax increases that pay for it and pledge to enact a new program that will be cheaper for taxpayers and consumers.
"I recognize that we can't keep Obama's promises," Representative Tom MacArthur of New Jersey said. "They were wrong to begin with, and the system can't be sustained." He worried aloud about the possibility that some people could lose insurance as the law is unwound.
"We're telling those people that we're not going to pull the rug out from under them, and if we do this too fast, we are, in fact, going to pull the rug out from under them," Mr. MacArthur said. After giving states the choice to expand Medicaid under the law, he said, reversing that expansion too quickly would run the risk of pulling a "bait and switch with the states."
The lawmakers' concerns contrasted with the confidence that Republican leaders and President Trump have expressed as they rush to replace Mr. Obama's signature domestic achievement, also known as Obamacare. Congress this month approved a budget blueprint that clears the way for quick action to repeal major provisions of the law, and Mr. Trump has said Congress should repeal and replace the law at the same time, putting pressure on lawmakers to agree on an alternative.
That budget measure created an aspirational deadline to draft repeal legislation by Jan. 27, a day that came and went.
Privately, Republicans made clear they understand the risks they are running. At their session this week, they voiced concern that their efforts to undo the law could have harmful consequences, such as inadvertently destabilizing insurance markets — a concern shared by Democrats and insurers.
Under Senate rules, the Senate could vote to repeal major provisions of the Affordable Care Act using fast-track procedures that neutralize the threat of a Democratic filibuster. "We can repeal parts of it," Mr. McClintock said, "and the parts that remain, I'm concerned, could make the market even more dysfunctional."
Republican leaders tried to reassure anxious backbenchers, making the same points in private as they have in public.
"We don't own Obamacare," said Senator John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee, adding: "We are the rescue party. We campaigned to provide relief and help repair the damage."
Republican leaders have predicted that Democrats will come to the table to help draft a replacement once it becomes clear that the health law will be repealed. But some rank-and-file members were not so sure.
Representative John Katko of New York wondered what Republicans would do "if we can't get anything out of the Democrats."
Another New York Republican, Representative John J. Faso, warned colleagues they were playing with fire if they cut off funds for Planned Parenthood clinics, as Speaker Paul D. Ryan has said Republicans intend to do.
"Health insurance is going to be tough enough for us to deal with, without allowing millions of people on social media to come to Planned Parenthood's defense," Mr. Faso said. He wanted to know from the administration that "we're not going to have a tweet from the president" saying "we should protect Planned Parenthood."
"We're making a grave mistake including this Planned Parenthood provision in a health care bill," he said.
For many Republicans, coverage and cost are still the most important issues. Estimates of the number of people who will gain or lose coverage will affect the outlook for any proposal to dismantle and replace the 2010 law. If the Congressional Budget Office, the nonpartisan scorekeeper on Capitol Hill, concludes that a significant number of people could lose coverage under a Republican plan, opposition from lawmakers — including Republicans — could jeopardize passage.
Before Mr. Trump stepped into the debate with his call for "insurance for everybody," Republicans were choosing their words with utmost caution: Their goal in replacing the health law was to guarantee "universal access," they said, not necessarily universal coverage.
"We will give everyone access to affordable health care coverage," Mr. Ryan said in early December when asked if Republicans had a plan to cover everyone.
But that discipline has broken down as lawmakers hear from constituents terrified of losing insurance and as Mr. Trump weighs in.
"No one who has coverage because of Obamacare today will lose that coverage," Representative Cathy McMorris Rodgers of Washington, the chairwoman of the House Republican Conference, said on Jan. 10.
A spokeswoman for Ms. McMorris Rodgers later tried to clarify what she had said. The congresswoman "didn't deliver her remarks exactly as prepared," the spokeswoman said. In the prepared remarks, Ms. McMorris Rodgers included an important qualification: "No one who has coverage because of Obamacare today will lose that coverage the day it's repealed" — in the transition to a new market-oriented health care system.
But Senator John Cornyn of Texas, the No. 2 Senate Republican, has made a sweeping commitment just like the one by Ms. McMorris Rodgers. After meeting with governors on Jan. 19, Mr. Cornyn was asked about concerns that people who benefited from the expansion of Medicaid might lose that coverage with a repeal.
"We're all concerned, but it ain't going to happen," Mr. Cornyn said. He amplified the point, adding: "Nobody's going to lose coverage. Obviously, people covered today will continue to be covered. And the hope is we'll expand access. Right now 30 million people are not covered under Obamacare."
A spokesman for Mr. Cornyn said he "meant no one will lose access to coverage."
Chris Jacobs, a health policy analyst who used to work for Republicans in Congress, said Republicans and Mr. Trump were at risk of overpromising, just as Mr. Obama did.
"Conservatives should not remain fixated on the number of people with health insurance when designing an Obamacare alternative," Mr. Jacobs said. "We will never win the battle with liberals if you measure success in terms of how many people have health insurance cards. We don't want to spend as much as liberals, and we don't believe in coercing people to buy insurance."
Democrats remember how Republicans hounded Mr. Obama for breaking his promise that "if you like your health care plan, you can keep your health care plan." Democrats say they will hold congressional Republicans and the Trump administration accountable in the same way.
Increasing the number of people with insurance was a lodestar for the Obama administration. It spent tens of millions of dollars advertising the benefits of the law. It extended deadlines to give people more time to sign up. It allowed many people to sign up outside the regular annual enrollment period and played down the significance of big premium increases, saying consumers could get subsidies to defray the costs.
Republicans say they can get the same results for less money and without a statutory mandate that most Americans have insurance. But without that requirement, budget analysts say, it will be difficult for Republicans to achieve coverage gains as large as those achieved under the Affordable Care Act.
"It's easier for the Congressional Budget Office to estimate significant coverage effects if there is a federal requirement" for people to have insurance, said Douglas W. Elmendorf, who was the budget office director from 2009 to 2015. "It would be very hard to maintain the levels of insurance coverage we have now without the penalties and subsidies."
Democracy is a pathetic belief in the collective wisdom of individual ignorance.
H. L. Mencken
Democracy is a pathetic belief in the collective wisdom of individual ignorance.
H. L. Mencken