Spurred on by President Donald Trump's latest call for action to repeal and replace the Obama health law, Republicans accelerated their work on Wednesday in a push to forge a GOP health care agreement, but even with a new sense of urgency, Republican leaders still face divides in the Congress on several key issues that could imperil the effort.
Let's take a look at some of the issues that are involved in GOP discussions:
1. Trump gives thumbs up to tax credits. This is one of the biggest issues right now in the health care debate among GOP lawmakers, whether you give Americans tax credits to help them buy health insurance. In his speech Tuesday night, the President plainly said "tax credits" - but that means different things to some GOP lawmakers. "A tax credit is just a subsidy in another form," frowned Sen. Lindsey Graham (R-SC). The idea has drawn opposition from conservative House Republicans, who worry it will be an expensive entitlement; that opposition from Sen. Rand Paul (R-KY) and others could threaten action in the Senate.
2. GOP leaders push to get a vote done. A day after President Trump's speech, House and Senate Republican leaders made clear they want to get moving on health care, with talk of votes in House committees as early as next week. That came as a bit of a surprise, since no health care bill is even in final form. Most GOP lawmakers are not involved in the negotiations, and so they are on the sidelines, not only waiting for the final language of the legislation, but also all the cost estimates and related facts and figures that go with it. Some of the machinations are starting to worry conservative groups like the Heritage Foundation.
3. Medicaid reform for the states. This is a very big issue, because it pits the 31 states which expanded their Medicaid programs under the Obama health law, against the 19 states that did not. Republicans like the generic idea that states can be given money through block grants, and then have the power to run their own Medicaid operation without massive red tape from Washington, D.C. But the level of money involved, along with how many people would be covered is a big stumbling block, as this has divided not only GOP lawmakers in Congress, but Republican Governors as well.
4. Taxing health benefits from your employer. As I wrote back in January, one option for the GOP was to treat health benefits provided through your job as a taxable benefit - like regular income. The idea is that such a a plan would help keep a lid on the increase in health care costs. That is still a part of the discussion. "The current tax code discriminates against people who don't get health insurance at work," Speaker Paul Ryan said earlier this week. It's still not clear what income level the cap would be at, and how much money that new tax would bring in, as no final bill is publicly available as yet.
5. There are not easy answers on health care. President Trump took some flak earlier this week when he said that "nobody knew health care could be so complicated" - and Republicans in Congress are finding that out as they try to navigate not only the issues, but the rules surrounding how the GOP can push a health bill through the Congress using the complex rules of budget reconciliation. While that allows Republicans to avoid any filibuster in the Senate, it also limits what can be part of that bill, and does not allow the GOP to repeal the entire Affordable Care Act. "I'm very concerned about that," said Rep. Trent Franks (R-AZ), who argues Senate reconciliation rules are causing "legislative contortions."
6. When can we expect a vote? The best case scenario for Republicans is to push a bill through the House and Senate before Easter - but there could be a number of hurdles that get in the way. There was even one report on Wednesday that votes would take place before cost estimates are received from the Congressional Budget Office. That might not wash with some conservative Republicans, who are worried about spending. "I haven't seen a final bill," said Rep. Mark Sanford (R-SC), who said he is withholding judgment on what his leadership is developing on health care.