Republicans Say They Want to Fix the Affordable Care Act. They Just Don’t Know What That Means.

With just weeks until Affordable Care Act tax subsidies are set to expire, many Republican lawmakers have pledged to find a solution for skyrocketing premiums.

The issue has ensnared Republicans in a complex policy debate about how to merge a short-term fix — or even fix anything at all — with longer-term changes to the law that has been the party’s bogeyman for more than a decade.

“There’s a recognition that we need to address the health care premium issue in the individual market,” Republican Rep. Jeff Hurd told NOTUS.

With just over 40 days until the credits expire on Dec. 31, Republican lawmakers have not coalesced around any solution. A solution, after all, would require the Republicans to detangle competing priorities within their party.

“I get the frustration,” Hurd continued, “and I share the frustration of my colleagues who understand the only reason we’re talking about subsidies is because the underlying health care costs are out of control, and the system is in profound need of reform, and the Affordable Care Act is anything but affordable.”

Hurd offered a bipartisan framework earlier this month to solve the problem with Republican Rep. Don Bacon and Democratic Reps. Tom Suozzi and Josh Gottheimer that would extend expiring ACA tax credits with an income cap between $200,000 and $400,000, as well as fraud-prevention provisions, just one of many trial balloons floating around the House and Senate to solve the problem.

Republicans have spent years railing against the ACA as a political foil, and many conservatives sense an opportunity to use the upcoming deadline as leverage to insist on a significant overhaul of the law.

President Donald Trump, aligned with conservative lawmakers, has long considered repealing and replacing the ACA, one of his marquee legislative priorities. However, his crusade to do so failed in the Senate during his first term. More recently, the White House proposed attaching health care reform to a second reconciliation bill. But Trump instructed Congress this week not to “waste your time and energy” on anything other than sending money directly to individuals affected by the premium spike.

Vulnerable, more moderate Republicans are prioritizing simpler solutions to quickly spare their constituents surging health care prices that are considered politically toxic. This comes after Democrats drew attention to the issue this fall by insisting on an extension during the longest government shutdown in history.

“The reality is we’re coming up on this deadline fast, so we need to do something,” Rep. Kevin Kiley said.

Kiley and Democratic Rep. Sam Liccardo introduced a bill to extend the ACA subsidies for two years, along with eligibility changes and fraud protections. Kiley told NOTUS that his legislation is a first step to take before the end of the year, adding that after passing it, lawmakers can move to negotiate and discuss broader health reform “that maybe will have more impact.”

“Give us a runway so people don’t have to pay the price,” Kiley continued.

Kiley was not the first Republican to file a piece of ACA legislation that would extend the subsidies. Rep. Jen Kiggans proposed a clean, one-year extension of the ACA tax credits alongside a group of bipartisan House members in September.

But the bill doesn’t seem to have enough buy-in. Rep. Brian Fitzpatrick, a cosponsor, told NOTUS that Kiggans’ bill is just “a fallback.”

“The one-year extension is really the last option because it’s better than nothing, but it’s still perpetuating what we believe to be a problematic construct: where there’s no income caps, where (the money) is going to the insurance company instead of the insured,” Fitzpatrick said. “I would analogize it to a car rebate going to the auto deal instead of the car purchaser.”

Fitzpatrick, co-chair of the bipartisan Problem Solvers Caucus, told NOTUS that Republicans from the group would be meeting Thursday to discuss what health care reform can be done by Dec. 31.

“We’re just going to put everyone’s ideas on the table and see where people are,” he continued.

Many more Republicans pushing for a fix to ACA tax credits said they support bigger changes to the ACA. There is an inherent tension for these Republicans between extending a program tucked within a sprawling law and disliking the law itself.

While Fitzpatrick voted against repealing the ACA in 2017, he said the law “failed to live up to its promises.” Kiggans told Virginia local news in October that Congress should pursue “meaningful changes” to the law. Another leading moderate, Rep. Mike Lawler, told Fox News Tuesday that “Democrats are admitting that Obamacare has failed.”

It is just that they don’t think that they can accomplish fixes to those underlying issues before the credits expire.

“The ACA is so expensive, it’s not working, but we’re not going to fix it before Dec. 31, so we’re going to have to do some kind of extension of these tax credits,” Bacon, one of the Republicans on the bipartisan framework, told reporters last week.

“The speaker will respond,” Bacon added. “I’m confident.”

The problem for moderates is that many conservatives and leadership consider a simple extension, essentially, a Band-Aid for a bullet hole.

House Majority Leader Steve Scalise suggested to reporters that “dumping hundreds of billions of dollars” into the ACA was a no-go. Instead, he said, “we’re big fans” of the Health Savings Account approach, where money goes to accounts held by patients that they can then use for out-of-pocket expenses.

The HSA route is more aligned with Trump’s demand that money be sent directly to the people, and conservative members seem to be behind it. House Freedom Caucus Chair Andy Harris told reporters he would not support an ACA credit extension and floated the idea of “health pay,” where patients use HSAs to cover their health care.

HSAs, however, do not address rising health premium costs and it’s likely Democrats would not support that idea on its own, particularly with their leadership currently backing a three-year ACA extension.

Democrats, whose votes will almost certainly be required in the Senate to pass any kind of health care legislation, told NOTUS they are skeptical that bipartisan collaboration will bear fruit before the Dec. 31 deadline.

“It’s going to be tough, just because everything is so toxic,” Rep. Tom Suozzi, a top Democratic top negotiator, told NOTUS.

And that’s just in the House. In the Senate, those talks around health care are more complex. There are massive divides on what would be acceptable in terms of reform to the law. Senate GOP Leader John Thune has acknowledged as much.

“We’ve got a lot of people who have strong views,” Thune told reporters Wednesday. “But the one thing that unites us is we all believe that we need to reform, and we’ve got to do something to drive health care costs down. I think the affordability issue is a big issue. I think it’s been exacerbated by the way Obamacare has been structured through the years.”

Senate Republicans have begun to coalesce around one proposal from Sen. Bill Cassidy, chair of the Senate Health, Education, Labor and Pensions Committee, to replace the tax credits with direct deposits into health care savings accounts — similar to conservatives’ idea in the House. But that is a ways away from Democrats’ ideal extension, leaving some sort of compromise as the only apparent hope for success.

“I’m not opposed to bipartisan deals,” Republican Sen. John Cornyn told reporters, adding that he likes the direction of Cassidy’s plan. “The problem was Obamacare was never a bipartisan deal. And so Democrats seem to be saying, ‘You need to swallow this partisan bill that was sold under false pretenses, and hasn’t delivered its promise.’ And that’s unacceptable.”

However, when asked by a reporter if he would accept some sort of compromise between Cassidy’s bill and what Democrats want, he replied: “I kind of like what Cassidy is saying. But the devil is in the details.”