Congressional Republicans are trying — yet again — to rework the Affordable Care Act, offering competing proposals to change the landmark health care law before pandemic-era subsidies expire at the end of the month.
But so far, the effort has triggered a free-for-all of competing GOP ideas and reinforced deep partisan divisions over the issue — leaving little chance of a bill reaching President Donald Trump’s desk before health insurance premiums rise for millions of Americans early next year.
The scramble has revived painful memories for some Republicans from Trump’s first term, when the party tried to repeal and replace the ACA but failed in dramatic fashion.
House and Senate Republicans in recent weeks have introduced at least nine different health care plans — including two with bipartisan support — with more in the works.
Some Republicans want to extend the ACA subsidies that Democrats enacted in 2021 before they expire at the end of the year, while others stress they were always temporary and argue they merely paper over the underlying problem of rising health care costs.
“The challenge Republicans have always had is trying to unify behind a single proposal,” Sen. John Cornyn (R-Texas) told reporters. “We’ve just got too many good ideas.”
On Thursday, the Senate plans to take up two competing bills — one offered by Republicans, the other by Democrats — with neither expected to pass.
Democrats will vote for a measure to extend the subsidies for another three years — a vote Senate Majority Leader John Thune (R-South Dakota) promised them as part of deal last month to end the government shutdown.
Republicans will take up legislation from Sens. Bill Cassidy (Louisiana) and Mike Crapo (Idaho) that would allow the subsidies to expire but would give many Americans up to $1,500 in tax-free accounts to spend on health care.
Both bills are expected to fail, because neither has the 60 votes required to overcome a filibuster.
Republicans also struggled to coalesce around their 2017 health care bill, which the Congressional Budget Office estimated would cause millions of Americans to lose coverage.
It was an easy target for Democratic attacks, and the entire effort ultimately collapsed after Sen. John McCain (R-Arizona) cast the deciding vote against a whittled-down measure on the Senate floor.
Most Senate Republicans were there for the 2017 fight, but only a handful of staffers who helped draft House and Senate measures to repeal and replace Obamacare are still on Capitol Hill.
Some Republicans argue that the party has never been comfortable crafting health care policy, because it is deeply entwined with government, which the party traditionally has sought to cut. Republicans tend to focus on reining in Medicare and Medicaid costs — which together consume roughly one-quarter of federal spending — while Democrats focus on measures to expand coverage to more people.
“It’s hard because Republicans aren’t central planners,” said Joe Grogan, director of the White House Domestic Policy Council during Trump’s first term.
The Republicans health care plans introduced in recent weeks are much more modest than the 2017 legislation. Instead of seeking to repeal and replace Obamacare, they attempt to replace the ACA subsidies enacted in 2021 that will expire at the end of the year.
“They are tiny by comparison,” said Doug Holtz-Eakin, a former CBO director who is president of American Action Forum, a conservative think tank. “These are rifle-shots of reform, and they’re not going to have a big impact on the larger health care delivery issue.”
Some of the Republican plans would extend the ACA subsidies for one or two years with changes that Republicans argue would help combat fraud in the program. Others — including the Republican bill the Senate is set to vote on Thursday — would fund health savings accounts instead.
“The Republican counterproposals are all over the place,” said Cynthia Cox, director of the ACA program at KFF, a health care think tank. “They span a really wide range here that is probably representing how fragmented Republicans are on health insurance issues more broadly.”
A plan from Sens. Bernie Moreno (R-Ohio) and Susan Collins (R-Maine), for instance, is similar to what Democrats and Republicans have discussed as the basis of a bipartisan compromise. A bill from Sen. Rick Scott (R-Florida) “could blow up the ACA marketplace” in some states if enacted, Cox said.
Sen. Josh Hawley (R-Missouri), who has expressed support for extending the subsidies, said he would vote for the Republican bill Thursday even though it would not do that. “Rather than sitting back and saying, ‘Well, I don’t like that part of it, and therefore I’m going to vote no on it,’ my attitude is I can find things to like,” Hawley said.
House Speaker Mike Johnson (R-Louisiana) has vowed that House Republicans will come up with their own proposal and vote on it next week before lawmakers leave for the holidays.
“We have some low-hanging fruit, we have some things that every Republican agrees to,” Johnson told reporters Wednesday. “You’re going to see a package come together that will be on the floor next week that will actually reduce premiums for 100 percent of Americans, not just the 7 percent” who receive the ACA subsidies that are set to expire.
The bill will not extend the expiring subsidies, according to House Majority Leader Steve Scalise (R-Louisiana), frustrating a small group of moderate Republicans.
One of them, Rep. Brian Fitzpatrick (R-Pennsylvania), bucked Johnson on Wednesday by introducing a discharge petition to force a vote on a bipartisan bill that would extend the subsidies with some changes.
“This is personal to a lot of us. These are our friends and our neighbors that are losing sleep over this,” Fitzpatrick told reporters Wednesday. “So we just have no time, no patience for the BS politics that sometimes consume this place.”
Senate Democrats for the most part have derided the Republican bills.
“Democrats are fighting to lower health care costs for the American people,” Senate Minority Leader Charles E. Schumer (D-New York) told reporters. “Republicans are fighting with each other. They can’t even come up with a plan.”
When Sen. Jon Husted (R-Ohio) sought unanimous consent Wednesday to pass his bill to extend the subsidies for two years, Sen. Tammy Baldwin (D-Wisconsin) blocked it from passage.
She argued that changes included in the legislation would lead millions more Americans to lose health insurance and would not prevent premiums from rising. She also criticized the bill barring plans bought using the subsidies from covering abortion.
“This bill is a deeply unserious proposal to a very serious problem,” Baldwin said on the Senate floor.
Some Democrats and Republicans view abortion as the biggest hurdle to striking a deal to extend the subsidies.
Republicans are under pressure not to agree to any deal unless it blocks health insurance plans bought using the subsidies from covering abortion — but that idea is anathema to Democrats.
Susan B. Anthony Pro-Life America, a leading antiabortion group, has threatened to try to unseat any Republicans who vote for a bill that does not include abortion restrictions, known as Hyde protections. The group targeted antiabortion Democrats who voted for the ACA in 2010 on the same grounds.
Many Republicans — including Thune and Johnson — have insisted that any health care bill must include Hyde language.
“I would never consider any form of subsidy extension without Hyde protections,” said Rep. Andy Harris (R-Maryland), the chairman of the conservative House Freedom Caucus.
Democratic and Republican senators are still discussing a potential compromise, and Thune has expressed optimism that those talks could gather momentum once the dueling bills fail Thursday.
Sen. Jeanne Shaheen (D-New Hampshire), who has been involved in the talks, said it is hard to see how such a bill could come together before subsidies expire at the end of the year, although Congress still could pass legislation in January.
“I think there is a path to get a compromise bill,” Shaheen said. “The question is whether there’s a commitment to do that on both sides of the aisle, and that’s not clear yet.”
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