WASHINGTON — House Speaker Paul D. Ryan, facing a revolt among conservative and moderate Republicans, rushed to the White House Friday afternoon to inform President Trump he did not have the votes to pass legislation to repeal the Affordable Care Act and to decide whether to pull the bill from consideration.
The president and the speaker faced the humiliating prospect of a major defeat on legislation promised for seven years, since the landmark health legislation was signed into law. President Trump had demanded a vote regardless, which has been scheduled for Friday afternoon. But House leaders were leaning against such a public loss.
The House opened debate Friday on what could be one of the most consequential pieces of legislation in years, a bill that could roll back a major, established social welfare program, a feat that is almost unheard of.
The Republican legislation, called the American Health Care Act, would end the Affordable Care Act’s mandate that almost everyone have health care, replacing it with a system of age-based tax credits to purchase health insurance — a shift that would save the government hundreds of billions of dollars and would cut taxes, but could leave 24 million more Americans without coverage in a decade, the nonpartisan Congressional Budget Office said.
Republicans said President Barack Obama’s signature domestic achievement, the 2010 health care law, had been a failure, disrupting coverage for millions of people and fueling big increases in health insurance premiums and out-of-pocket medical costs. Insurers in many states, they said, were losing hundreds of millions of dollars under the health law and have dropped out of the public marketplaces.
“For seven years, Americans have been hurt by Obamacare,” said Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee. “They have pleaded with Congress to get the government out of the examining room and give them health care they can afford. This failed Obamacare experiment is over. It’s time to act.”
President Trump chimed in from Twitter, declaring, “After seven horrible years of ObamaCare (skyrocketing premiums & deductibles, bad healthcare), this is finally your chance for a great plan!”
On Twitter, Donald Trump took a shot at the hard-line House Freedom Caucus, which has pressed for more conservative policies, calling it ironic “that the Freedom Caucus, which is very pro-life and against Planned Parenthood,” would oppose a bill that strips federal funds from the women’s health provider — albeit for a single year.
But Republican divisions were still on public display. Representative Rodney Frelinghuysen of New Jersey, chairman of the powerful House Appropriations Committee, announced Friday that he would oppose the Republican bill, joining other moderates from Northeastern states.
Democrats kept their focus on the law that Republicans hoped to repeal, saying it had provided coverage to at least 20 million people. In the last 48 hours, they said, the repeal bill became worse as Republicans cut deals to woo support from the most conservative members of their party.
The Democrats were particularly critical of a last-minute decision by House Republican leaders to scrap federal standards for the benefits that must be provided in health insurance policies.
“I don’t have the ability to adequately express my outrage,” said Representative Jim McGovern, Democrat of Massachusetts. “The Republican bill would return us to the day when insurers sold woefully inadequate policies with few protections. This back-room deal will kill the requirement for insurance companies to offer essential health benefits such as emergency services, maternity care, mental health care, substance addiction treatment, pediatric services, prescription drugs and many other basic essential services.”
Republicans tried to address these concerns with an amendment filed late Thursday night.
The amendment requires states to establish their own standards for “essential health benefits,” for the purpose of deciding which health plans can be used by people receiving federal tax credits to help pay premiums. The amendment also provides $15 billion in additional funds to states for “maternity coverage and newborn care” and for the “treatment of addiction and mental illness.”
Mr. Trump issued an ultimatum on Thursday to recalcitrant Republicans to fall in line behind a broad health insurance overhaul or see their opportunity to repeal the Affordable Care Act vanish. He demanded a vote on Friday on a bill that continued to appear to lack the majority needed to pass.
The demand, issued by Mr. Trump’s budget director, Mick Mulvaney, in a Thursday evening meeting with House Republicans, came after a marathon day of negotiating at the White House and in the Capitol in which Mr. Trump — who has boasted of his deal-making prowess — fell short of selling members of his own party on the health plan.
Mr. Ryan emerged from the session and announced curtly that Mr. Trump would get his wish for a vote on Friday. Mr. Ryan refused to answer reporters’ questions about whether he expected the measure to pass.
Some conservatives were still concerned that the bill was too costly and did not do enough to roll back federal health insurance mandates. Moderates and others were grappling at the same time with worries of their states’ governors and fretted that the loss of benefits would be too much for their constituents to bear.
Privately, White House officials conceded that competing Republican factions were each demanding changes that could doom the effort, placing the measure in peril and Mr. Trump’s chances of succeeding at a high-stakes legislative deal in jeopardy. With some of its demands in place, the Freedom Caucus ratcheted up its requests, insisting on a repeal of all regulatory mandates in the Affordable Care Act, including the prohibition on excluding coverage for pre-existing medical conditions and lifetime coverage caps.
Mr. Trump, who has promoted his negotiating skills and invited the label “the closer” as the vote approached, was receiving a painful reality check about the difficulty of governing, even with his own party in power on Capitol Hill.
“The choice is yes or no,” Representative Joe L. Barton, Republican of Texas and a member of the Freedom Caucus, said on Thursday night. “I’m not going to vote no to keep Obamacare. That’d be a stupid damn vote.”
Others were unconvinced.
Having secured Mr. Trump’s acquiescence to eliminate the requirement that insurers offer “essential health benefits,” members of the Freedom Caucus pressed their advantage. While they did not specify precisely which regulations they wanted to eliminate, the section they wanted to gut requires coverage for pre-existing health conditions, allows people to remain on their parents’ health care plans up to age 26, bars insurers from setting different rates for men and women, prohibits annual or lifetime limits on benefits, and requires insurers to spend at least 80 percent of premium revenue on medical care.
As of late Thursday night, their bluff called, many members of the caucus — a loose group of conservatives who refuse to divulge a full member list — were scrambling to bring at least some members on board. While many had clearly hoped that a shortage of votes would cause Mr. Ryan to decline to bring the bill to the floor, saving them from having to vote against the new president from their party, that strategy backfired.
“We’re committed to stay here until we get it done,” Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus, said on Thursday. “So whether the vote is tonight, tomorrow or five days from here, the president will get a victory.”
He said 30 to 40 Republicans planned to vote “no”; House leaders can afford to lose only 22 votes and still pass the bill.