Some Lawmakers Now Look to Bipartisanship on Health Care
WASHINGTON -- The sudden death of legislation to repeal the Affordable Care Act has created an opening for voices from both parties to press for fixes to the acknowledged problems in President Barack Obama's signature health law, as lawmakers and some senior White House officials appealed for bipartisanship.
But the White House, still smarting from a disastrous defeat on Friday, appeared uncertain on the path forward. President Trump predicted that "Obamacare will explode" and offered no plan to stop it, but his was not the only voice from the White House.
The president "wants to make sure that people don't get left behind" in the search for affordable, quality health care, Reince Priebus, the White House chief of staff, said on "Fox News Sunday."
"I think it's time for our folks to come together," Mr. Priebus said, adding that it is time to "potentially get a few moderate Democrats on board, as well" as they try to bring down premiums and stabilize insurance markets.
That appeal was echoed by Senator Susan Collins of Maine, a moderate Republican who opposed the House Republicans' health bill and has also worked with Democrats to explore changes to the Affordable Care Act without repealing it.
"With the demise of the House bill, there's a real window of opportunity for a bipartisan approach to health care," she said.
In the wake of the Republican failure to make good on the seven-year-old promise to repeal the Affordable Care Act, Mr. Trump and congressional leaders find themselves at a political crossroads.
They could sabotage the Affordable Care Act's insurance markets, betting that Democrats would be blamed for collapsing coverage choices and spikes in insurance premiums and would then come to the negotiating table ready to toss the law and start fresh. Or they could work with Democratic lawmakers and moderate Republicans, who for years have discussed improvements to the Affordable Care Act, which, unlike many social welfare programs, has not been significantly updated or revised.
Speaker Paul D. Ryan has said he wants to move on to other issues, and indicated that Democrats would have to come to him if they want to cooperate on health care. After insisting that the health law had to be eradicated "root and branch," Senator Mitch McConnell of Kentucky, the majority leader, has been remarkably quiet since Friday's debacle.
The messages from the White House, so far, have been mixed. "You cannot fix a broken system," the White House budget director, Mick Mulvaney, said on NBC's "Meet the Press." "You are never going to fix that. This system must be removed." Mr. Trump appeared to endorse the crash-and-burn strategy on Saturday morning, saying on Twitter: "ObamaCare will explode and we will all get together and piece together a great health care plan for THE PEOPLE. Do not worry!"
But Mr. Priebus's softer vision gave some in Congress hope that a bipartisan approach could be found -- possibly to alleviate the health law's burdens on small business, repeal some of its more unpopular taxes, give employers more leeway on which employees they have to offer insurance to, and foster more competition among insurance companies. "I believe that there is a group of centrist Democrats who recognize that the Affordable Care Act has flaws that must be fixed," Ms. Collins said. "Until there was a repudiation of the House bill, they felt constrained from negotiating. Now that the House bill has died, I hope they will feel free to come to the table."
Representative Don Young, Republican of Alaska, also called for bipartisanship. His state has benefited from its expansion of Medicaid under the health law, and would have been punished under the House Republican bill because its high premium costs would not have been offset by larger tax credits, as they are under current law.
"The reason why Obamacare failed was because it wasn't a bipartisan bill," Mr. Young said. Republicans, he said, made the same mistake, writing their bill without Democrats. "We were very frankly guilty of that," he said.
Democrats also sounded more conciliatory.
"Until now, we haven't talked at all about compromise on the Affordable Care Act," said Representative Diana DeGette, Democrat of Colorado. "From the moment it passed, Republicans started their mantra of 'repeal and replace.' Now that repeal seems to be off the table, I think it's in everybody's interest to make the law work better for our constituents."
Representative Jim Cooper, a centrist Democrat from Tennessee who has often worked with Republicans, said: "We need to fix the flaws in Obamacare. I hope Republicans are willing to do that, instead of just destroying Obamacare." But, he added, "before we can work with them, the Republicans have to bargain in good faith and stop sabotaging Obamacare."
Mr. Obama's health care law may not be imploding, as President Trump says. But in states as diverse as Alaska, Arizona, Minnesota, North Carolina and Pennsylvania, the public insurance marketplaces -- a central innovation of the Affordable Care Act -- are in trouble. Consumers have seen big premium increases for health plans sold by a shrinking number of insurers. "People will have to come to the bargaining table sooner rather than later," said Chris Jacobs, a health policy analyst.
Within a few weeks, insurers must decide whether they will participate in the marketplaces in 2018. Insurance markets could quickly unravel if the House wins a court case challenging the legality of subsidies paid by the government to insurers on behalf of low-income people.
"The comments by President Trump and Speaker Ryan predicting the collapse of the A.C.A. and health insurance exchanges could become a self-fulfilling prophecy," said Kevin J. Counihan, who was the chief executive of the federal insurance marketplace, HealthCare.gov, under Mr. Obama.
Mr. Counihan said he saw a risk that some counties might not have any insurers on the exchange next year as major insurers like Aetna, Humana and UnitedHealth pull back from the program. Republicans in Congress, especially those from rural areas, share that concern. The Obama administration worked hard to keep insurers in the market, and to promote sign-ups during open enrollment season. Whether the Trump administration will do so is unclear.
Mr. Counihan suggested several areas where Republicans and Democrats in Congress could work together. They could, he said, give insurers more discretion to charge higher premiums for older adults, reflecting their medical costs. Under the Affordable Care Act, insurers can charge older adults no more than three times the rates for young adults. The House Republican bill would have allowed them to charge five times as much, or more if states wanted. A ceiling somewhere between those numbers might be appropriate, Mr. Counihan said.
In addition, he said, Congress could shorten the length of "grace periods" during which insurers must provide coverage to consumers who fail to pay their premiums. Lawmakers from both parties have also expressed a desire to give states more freedom to pursue their own ideas for expanding coverage, controlling health costs, reducing premiums and stabilizing insurance markets. Giving states more flexibility is consistent with Republicans' federalism philosophy. It also has potential appeal to Democrats because many states, including some with Republican governors, are to the left of the Trump administration on health policy.
One section of the Affordable Care Act, added at the behest of Senator Ron Wyden, Democrat of Oregon, already allows waivers for innovations in state health policy. But states say the requirements are so stringent that the waivers are of limited use.
"As Republicans, we know that one-size-fits-all works for no one and certainly did not work for the individual markets," said Representative Michael C. Burgess of Texas, the chairman of the Energy and Commerce subcommittee on health. Lawmakers of both parties also support legislation to help small businesses get insurance. As a possible model for bipartisan cooperation, they point to a bill signed by Mr. Obama in 2015 that changed the definition of "small employer" to protect such companies against increases in health insurance premiums.
The possibility of bipartisan cooperation may not last long. Some conservative Republicans like Senator Rand Paul of Kentucky and Representative Sean P. Duffy of Wisconsin said they would redouble their efforts to undo the Affordable Care Act. "Rip it all out by the roots!" Representative Steve King of Iowa said Friday in a Twitter post.
But other Republicans said that Democrats should be involved in efforts to rewrite the law. Representative Mark Sanford, Republican of South Carolina, opposed the House bill and said its demise could "prove to be a catalyst" for forging a consensus. "Seeming stopping points can ultimately prove to be beginning points in life," he said.