House speaker Paul Ryan said he and other Republican leaders will make ‘necessary improvements’ to the legislation as they scramble to boost support

Their healthcare overhaul imperiled from all sides, the White House and top House Republicans acknowledged on Wednesday that they would make changes to the legislation in hopes of nailing down votes needed to pass the the party’s showpiece legislation soon.



House speaker Paul Ryan declined to commit to bringing the measure to the House floor next week, a fresh indication of uncertainty. Republican leaders have repeatedly said that was their schedule, but opposition mushroomed after a congressional report concluded this week that the measure would strip 24 million people of coverage in a decade.

Ryan told reporters that he and the other Republican leaders could now make “some necessary improvements and refinements” to the legislation, reflecting an urgency to buttress support.

Republican healthcare plan: 24 million people could lose coverage, CBO reports Read more

Though the bill cleared another hurdle in the House Thursday, winning approval of the House budget committee, three conservatives voted against the bill, underscoring the party’s divide. The Republican chair of the committee, Diane Black, called the bill “a good first step”.

The measure would strike down much of former president Barack Obama’s 2010 overhaul and reduce the federal role, including financing, for healthcare consumers and is opposed uniformly by Democrats.

On Wednesday night, Donald Trump told a rally in Nashville, Tennessee: “It’s going to be great.”

He added: “The House has put forward a plan to repeal and replace Obamacare [the Affordable Care Act], based on the principles I outlined in my joint address. Let me tell you, we’re going to arbitrate, we’re going to get together, we’re going to get something done.

“Remember this. If we didn’t do it the way we’re doing it, we need 60 votes, so we’d have to get the Democrats involved. They won’t vote, no matter what we do, they’re not going to vote. So we’re doing it a different way, a complex way, it’s fine. The end result is when you have phase one, phase two, phase three, it’s going to be great. And then we get on to tax reduction, which I like.”

At an all-hands meeting of House Republicans, Mike Pence and party leaders urged their rank-and-file to unite behind the legislation.



“It’s our job to get it out of here and get it to the Senate,” the vice-president told the Republican leaders, according to Dennis Ross, a congressman for Florida. That would let Trump pressure “Democrats in these red states to come on board”, Ross said, referring to Republican-leaning states where Democratic senators face re-election next year.

Health secretary Tom Price was using phone calls to lobby Republican governors, some of whom oppose the bill’s phasing out of Obama’s expansion of Medicaid to 11 million lower-income Americans.

Amid the maneuvering, a government report said that more than 12 million people have signed up for coverage this year under the very statute that Donald Trump and congressional Republicans want to repeal. That figure underscored the potential political impact of the party’s next move.

Pence met repeatedly with House Republicans but rebels still abounded. Conservatives were unhappy the measure doesn’t erase enough of Obama’s law while at the other end of the party’s spectrum, moderates were upset the bill would strip millions of health coverage.

Conservatives want to end Obama’s expansion of Medicaid next year, not in 2020 as the bill proposes. They also say a tax credit to help people pay medical costs is too generous, and they want to terminate all of Obama’s insurance requirements, including mandatory coverage of specified services like drug counseling.

Why is healthcare so expensive in the USA? It’s the prices. That’s not a joke. Drugs, diagnostics, medical devices, doctor visits, hospital visits, procedures, scans, surgeries – “the United States spends more on health care than any of the other OECD countries spend, without providing more services than the other countries do ​, ​”, according to a widely cited 2003 paper on the topic entitled It’s the Prices, Stupid. Why are prices so high? In short, lack of a national system. The US system is employer-based, with most Americans – about 150 million non-elderly people – getting insurance through their employers, instead of straight from Washington. No national system means there is no single authority – no single payer – to go to bat on behalf of the consumer, although the big public healthcare programs, Medicare and Medicaid, do negotiate with providers on some costs. US healthcare providers can therefore get away with charging more, as can medical device manufacturers and drug makers. Doctors can order more tests, ambulances can charge more for transport and, on the other side, insurance companies can put up stronger resistance to paying claims, or charge more for coverage. The enormous inefficiency of the system is itself costly, as all sides have to spend money on analysts and lawyers and bookkeepers and anxiety medication. Why can’t market forces resolve the problem? Because it’s a highly irregular market, with highly localized supply and demand, instantly fluctuating demand (from no-need to need-now-at-any-price) and high barriers to entry for would-be suppliers of insurance, pharmaceuticals, or care itself. Tom McCarthy

Meanwhile, moderates in the same party feel the tax credits are too stingy, especially for low earners and older people. They oppose accelerating the phaseout of the Medicaid expansion and are unhappy with long-term cuts the measure would inflict on the entire program.

Terminating the Medicaid expansion in 2020 and not 2018 “is sacrosanct to me”, said Tom MacArthur, a congressman for New Jersey.

In a new complication, Charles Grassley, a Republican senator for Iowa, said the measure lacked the votes to pass in the Senate, where Republicans hold a precarious 52-48 majority. That left House members angry over being asked to take a politically risky vote for legislation likely to be altered.

Moderates “don’t like the idea of taking a vote in the House that may go nowhere in the Senate”, said Charlie Dent of Pennsylvania.

The bill would enfeeble Obama’s individual mandate, the requirement that Americans buy coverage, by abolishing the tax fine on violators. It would end subsidies that help low-income people with high insurance premiums the most and replace them with tax credits that are bigger for older people. It would cut Medicaid, repeal the law’s tax increases on higher earning Americans and require 30% higher premiums for consumers who let coverage lapse.

GOP support became scarcer when the nonpartisan Congressional Budget Office projected the legislation would push 24 million Americans off coverage in a decade and shift out-of-pocket costs toward lower income, older people. That surpasses the 20 million who’ve gained Medicaid or insurance coverage under Obama’s law.

Hundreds of conservative activists rallied outside the Capitol in sub-freezing weather to call on congressional leaders and Trump to abandon the GOP bill and fully repeal Obama’s law. The rally was organized by FreedomWorks, a conservative group backed by the billionaire Koch brothers.

The 2017 government sign-up numbers missed Obama’s target of 13.8 million people. Experts said the figures undercut Republican claims that the health law’s insurance markets are teetering toward collapse.