Health care plan circulated by the White House runs into familiar GOP divisions

WASHINGTON (AP) — A health care proposal circulated by the White House in recent days is running into the reality of Republican divisions on the issue — a familiar struggle for a party that has been trying to scrap or overhaul the Affordable Care Act for the past 15 years.

The tentative proposal from President Donald Trump would extend expiring ACA subsidies for two years while adjusting eligibility requirements for recipients. The plan has so far been met with a stony silence on Capitol Hill as Republicans debate among themselves whether to overhaul the law, tweak it or simply let the subsidies expire.

It’s unclear now when the White House plan might be released, or if it will be released at all.

The Republican indecision comes as the COVID-era tax credits are set to expire Jan. 1, creating sharp premium increases for millions of Americans. Democrats who shut down the government for six weeks over the issue are demanding a straight extension with no changes, though some indicated they could support a plan similar to the one circulated by the White House.

But support may be harder to find in the GOP conference, where many lawmakers say costs are still too high and have been eager to make another run at repealing the ACA. The last effort in 2017 failed when Republicans couldn’t decide on how to provide coverage to millions of Americans who depend on government-run marketplaces for their health care. It's a dilemma that persists for the party after record numbers signed up for coverage this year.

Senate Majority Leader John Thune, R-S.D., promised a group of moderate Democrats a vote on the ACA tax credits by mid-December in exchange for their votes to end the government shutdown. But it’s unclear, so far, whether that arrangement will lead to a solution.

Bipartisan compromise?

Health care has long been one of the most politically fraught topics on Capitol Hill, so a bipartisan compromise seems unlikely. But the coming price spikes have motivated some lawmakers to look for points of agreement.

Republican Sen. Thom Tillis of North Carolina said last week that he hopes the subsidies are extended.

“I’m sure some of my colleagues will be mad at me for saying this — if we don’t address the subsidies issue in December, I don’t think it’s going to get addressed next year,” Tillis said, adding that Democratic campaigns will be “just churning up all the very sympathetic stories” if it isn't fixed.

The draft White House proposal would put new income limits on the tax credits — at 700 percent of the federal poverty level, according to two people with knowledge of the proposal who requested anonymity to discuss it. The White House would also require those on Obamacare, regardless of the type of coverage, to pay some sort of premium for their plans. That would effectively end zero-premium plans for those with lower incomes, addressing a concern from Republicans who say the program has enabled fraud.

Some Democrats have suggested they are open to those ideas as a part of broader negotiations. “I’m glad the president is reportedly considering a serious proposal,” said New Hampshire Sen. Jeanne Shaheen, one of the Democrats who voted to end the shutdown.

Some Republicans have signaled support as well. Nebraska Rep. Mike Flood, the chairman of the business-oriented Republican Main Street Caucus, said in a statement that the group supports “President Trump’s ongoing efforts to address the ACA tax credit cliff with an extension.”

Several bipartisan bills in the House would extend the ACA credits for two years, with changes such as income limits for the enhanced credit. “I think two years is really the sweet spot where everybody is OK,” said Pennsylvania Rep. Brian Fitzpatrick, a co-chair of the bipartisan Problem Solvers Caucus.

Premium spikes on Jan. 1

Still, House Speaker Mike Johnson, R-La., has declined to say whether he will allow a vote on a health care bill. Many other members of his GOP conference want to see the subsidies eliminated or the underlying law overhauled. In addition, Thune and other Republicans have said they want new language on abortion restrictions if they pass an extension — a dealbreaker for Democrats.

If Congress doesn’t act, the enhanced premium tax credits that have helped many Americans pay for Affordable Care Act health insurance plans will disappear. And premiums could more than double for subsidized enrollees, according to an analysis by the health care research nonprofit KFF.

Signups for next year’s insurance began on Nov. 1, meaning that many Americans are already planning for the higher costs. Democrats who forced the shutdown at the beginning of October had hoped to negotiate an extension before open enrollment began.

“When people’s monthly payments spike next year, they will know it was Republicans that made it happen,” Senate Democratic leader Chuck Schumer said last week.

Republicans could go at it alone

As Democrats elevated the health care issue during the shutdown, some Republicans saw an opportunity to renew their efforts to overhaul the law. GOP lawmakers in the House and Senate have been meeting to find consensus, though they haven't found it yet.

Among the GOP ideas are separate proposals from Florida Sen. Rick Scott and Louisiana Sen. Bill Cassidy to use savings accounts to either shop for insurance or defray out-of-pocket costs. Scott’s legislation would create what he called “Trump Health Freedom Accounts” and make some changes to the health care law, including by allowing consumers to shop across state lines. Cassidy’s narrower bill would create new savings accounts just to replace the enhanced subsidies that are expiring.

The draft of the White House plan, meanwhile, would allow those in lower-tier plans, such as the bronze-level or catastrophic plans, to put money into health savings accounts.

Those proposals are unlikely to win over Democrats. Schumer said last week that the savings accounts “will go nowhere in the Senate.”

Skeptical that the two parties will ever agree, some Republicans have suggested that they try to pass a health care package using budget maneuvers similar to Trump’s “ Big Beautiful Bill ” of tax and spending cuts. If it worked, they could pass the legislation with zero Democratic votes — a politically risky strategy that could take months, well into the midterm election year.