WASHINGTON — White House officials, desperate to demonstrate progress on President Trump’s promise to repeal the Affordable Care Act, are pushing to resurrect a revamped version of a Republican health care bill before his 100th day in office next week bill.
Some members of the president’s team have grown consumed by the marker, worrying that public appraisals at this traditional evaluation period will be brutal and hoping that a last push might bring a measure of salvation.
But at the same moment Mr. Trump’s hundred-day mark is reached on Saturday, April 29, there is a far more urgent deadline: Much of the federal government will run out of money. Reaching agreement on a measure to keep the government open past midnight that Friday will be the first priority of Republican leaders when Congress returns Monday from a two-week spring recess.
“I believe that when we first go back, that’s going to be the thing we’ll address immediately and have to get done by Friday,” said Representative Dan Donovan, Republican of New York.
Republican leaders and the White House have been searching for a health care compromise that could placate enough moderates and hard-line conservatives to win passage in the House.
The latest version of the proposal, published Thursday morning in Politico, would maintain popular benefits in President Barack Obama’s signature domestic achievement, like guaranteed coverage for emergency services and maternity care. It would also preserve the health law’s ban on insurers rejecting customers with pre-existing medical conditions.
But under the compromise Affordable Care Act replacement, states could seek waivers from many of those mandates if they could demonstrate that premiums would be lowered. States could request an exemption from the existing health law’s “community rating” rule intended to ensure that people with pre-existing conditions could not be charged prohibitive premiums — but only if those states establish a high-risk insurance pool where such consumers could purchase government-subsidized insurance.
But the complications that remain may be far too difficult to finesse at the same time the House and Senate press to pass a giant spending bill.
Tussles over the spending deadline — including possible debates over top administration priorities like a border wall and money for immigration enforcement officers — are expected to consume the Capitol. And Democrats — whose votes will be needed to keep the government open — will have their own demands, most importantly billions of dollars in subsidies for health insurance companies to lower deductibles and other forms of spending for low-income Americans purchasing health coverage on the Affordable Care Act’s online marketplaces.
Senior Republicans appear unconvinced that a revised health care bill would assure passage in the House. Mr. Donovan, an opponent of the original Republican health care bill, said the proposed amendment “really doesn’t address the concerns that I had.” He has cited reservations over how the legislation affects seniors and provisions that would particularly disadvantage New York City.
Mr. Donovan also expressed doubts about any aggressive timeline for approving the legislation, given the potential shutdown next week.
On health care, he said, “there may be some talk when we first get back, but I think the real push will probably happen after.”
The changes — proposed by Representative Tom MacArthur, Republican of New Jersey and co-chairman of the moderate House Tuesday Group — offer a possible balm for Republicans facing angry crowds at home over their failure to act on longstanding campaign pledges. A conference call for House Republicans had already been scheduled for Saturday, ahead of lawmakers’ return to Washington next week.
“We’re in the midst of negotiating sort of finishing touches,” Speaker Paul D. Ryan said this week in London while leading a congressional delegation.
He added: “It’s difficult to do. We’re very close. It’s basically, make good on the promises that were made.”
But the legislation’s future is unclear. For now, the proposal exists only in vague talking points. West Wing advisers to Mr. Trump are decidedly mixed in their views of how aggressively to raise expectations. The aide feeling perhaps the most pressure, according to people close to the discussions, is the chief of staff, Reince Priebus, who was blamed internally for the botched vote count around the first repeal effort and is closest to Mr. Ryan within Mr. Trump’s circle.
The initial bill’s failure has left lawmakers wary of artificial deadlines. Its inability to garner enough support last month to be brought for a vote in the House was an embarrassing setback for Mr. Trump, Mr. Ryan and the Republican conference.
Earlier this month, Vice President Mike Pence and other Trump administration officials sought to resuscitate the effort, working toward a new agreement with the conservative House Freedom Caucus, whose opposition helped fell the first bill. The measure, which gained little traction, quickly earned a nickname on Capitol Hill: Zombie Trumpcare.
Regardless of the bill’s fate, lawmakers are approaching a critical moment on health care. Health insurers and business groups are pressing hard for Republicans and Mr. Trump to maintain subsidies for health insurance ahead of insurers’ decisions in the coming weeks on whether to keep offerings on the Affordable Care Act’s marketplaces and how much to charge for them.
In recent weeks, the insurance companies have been strongly urging the Trump administration and Congress to commit to funding so-called cost-sharing reductions, warning that without the money from the government, the companies will have to sharply raise the prices of their plans offered through the state marketplaces. Some insurers have hinted they will leave the markets altogether without the funding.
About seven million people now qualify for the subsidies, which reduce the amount someone has to pay in deductibles and co-payments when they buy a plan. At stake is roughly $10 billion in payments expected to be made to the insurers this year. Some House Republicans oppose how the Obama administration funded them, and they won a court case potentially blocking the funding that is now on appeal. The next court date is May 22.
Earlier this week, insurance executives met with Medicare officials to plead their case. They left that meeting with Seema Verma, the new Medicare head, with no promises. Mr. Trump has publicly toyed with the idea of withholding the subsidies as a way to force Democrats to negotiate over the House proposal, and Ms. Verma told the insurers they should look to Congress to appropriate the money.
State insurance regulators weighed in on Wednesday, sending a letter to Congress urging it to fund the subsidies for this year and next. “Your action is critical to the viability and stability of the individual health insurance markets in a significant number of states across the country,” officials from the National Association of Insurance Commissioners wrote.
Insurers must begin the process of filing rates in the coming weeks. These deadlines vary state by state, and companies have the option of dropping out before they sign a final contract with the government to offer coverage in the marketplaces sometime this fall.
Many are now looking at various scenarios, said David M. Dillon, a fellow at the Society of Actuaries, who has been working with state regulators and insurers about how to price plans in the marketplace. Many will be revising their rates in the coming months as the environment becomes clearer. Insurers say their rates could be as much as 30 percent higher, and they say the market could be destabilized with prices so high.
Insurers remained largely silent on the proposed amendment, which seemed to revive a discussion of how to handle the sickest and most costly individuals by allowing states to set up high-risk pools. The insurers have previously indicated they would be open to ideas that helped pay for people with very expensive conditions.
By separating off these individuals, the cost of coverage for everyone else goes down, making it a potentially popular idea, said Stephen Zuckerman, the co-director of the Health Policy Center at the Urban Institute. But these pools have traditionally been poorly funded, leaving many people with potentially expensive pre-existing medical conditions without affordable coverage, if they can buy a plan at all.
“Why would these high-risk pools work better now than they have historically?” Mr. Zuckerman asked. “You have to have a lot of funding. “
Whether the majority of states have the time or the political will to tackle some of these issues is unclear.
“There would be really, really pitched battles in states,” said Katherine Hempstead, a policy expert at the Robert Wood Johnson Foundation.