WASHINGTON—Republican leaders are betting that the only way for Congress to repeal the Affordable Care Act is to set a bill in motion and gamble that fellow GOP lawmakers won’t dare to block it.
Party leaders are poised to act on the strategy as early as this week, after it has become obvious they can’t craft a proposal that will carry an easy majority in either chamber. Lawmakers return to Washington Monday after a week of raucous town halls in their districts that amplified pressure on Republicans to forge ahead with their health-care plans.
Republican leaders pursuing the “now or never” approach see it as their best chance to break through irreconcilable demands by Republican centrists and conservatives over issues ranging from tax credits to the future of Medicaid.
The new strategy means the health-care law could be overhauled in three precarious steps—reflecting the difficulties of concurrently repealing and replacing the law, as President Donald Trump had sought.
Republicans can afford to lose no more than two GOP votes in the Senate and 22 in the House, assuming they get no support from Democrats. That means any GOP faction could torpedo the repeal effort by withholding its support—and members of each have threatened as much.
Advocates of the strategy hope that knife’s-edge math will be an asset rather than a liability. They are betting different groups of Republican lawmakers can be pacified with a handful of concessions, then will swallow hard and vote for a longstanding repeal pledge, first in the House, then in the Senate.
“You’re a Republican, you’ve been running to repeal Obamacare, they put a repeal bill in front of you... Are you going to be the Republican senator who prevents Obamacare repeal from being sent to a Republican president who is willing to sign it?” said Doug Badger, a longtime Republican leadership health policy adviser.
Mr. Trump, House Speaker Paul Ryan (R., Wis.) and Senate Majority Leader Mitch McConnell (R., Ky.) are staking almost everything on this bet, because their entire domestic policy agenda, including a highly prized tax overhaul, rests on the health-care maneuver paying off first.
GOP leaders hope to push through Congress along party lines a bill now being drafted in the House that would repeal major chunks of the health law, according to Republican aides and lawmakers. The move would require use of the “reconciliation” process in the Senate, which lets measures that are generally budget-related pass with a simple majority instead of 60 votes.
The first step also could enact some elements of a new system, such as expanded health savings accounts popular with many Republicans, GOP aides and lawmakers said. It could potentially include alternative forms of financial assistance for people with private coverage and states that want to maintain Medicaid eligibility for low-income residents. It would likely include a transition period designed to prevent people losing coverage abruptly.
Health and Human Services Secretary Tom Price could write rules designed to ease the way for members worried that their states’ fragile insurance markets could collapse amid, or because of, GOP changes to the health law.
Later, Republicans could look to pass other components of their health-care plan, potentially in a string of bills, which would need 60 votes and bipartisan support in the Senate.
The plan could be torpedoed by everything from Republican divisions to public backlash to Democratic resistance. House Democratic leader Nancy Pelosi of California said on ABC’s This Week on Sunday morning that she didn’t believe Republicans would be able to follow through with their repeal bid.
“They won’t be able to do that,” she said. “How can they do it? They do not have the votes.”
Republican leaders see little alternative but to try, especially since they are already facing criticism for failing to move faster. Some conservative advocacy groups, such as Heritage Action, have said swifter movement could have forestalled the town hall meetings and the polls showing increased support for the ACA that are now rattling some centrist Republicans.
The town halls have also invigorated some conservative lawmakers, who are eager for the fight. “Not everyone is going to get what they want,” said Rep. Scott DesJarlais (R., Tenn.). “I’ve been telling people back home if they don’t see major movement on this by Easter, there’ll be reason to be concerned.”
Republicans still have to overcome significant divisions on central issues.
The House GOP has splintered, for example, over what financial assistance, if any, to offer in place of the ACA’s tax credits. Republican leaders are leaning toward including a new tax credit that would be refundable, pegged to consumers’ age rather than their income, according to a draft GOP plan released earlier this month.
But some conservatives view that as little better than the ACA subsidies they decry. “It’s a long fancy title for an entitlement program,” said Rep. Jim Jordan (R., Ohio).
Equally divisive is a battle over Medicaid, the federal-state insurance program for the poor. Republican senators from states that accepted an ACA provision allowing them to use federal funding to expand Medicaid generally want to keep it. Those from states that rejected the expansion are just as determined to see a distribution of federal dollars that doesn’t punish them for turning down the enlargement.
Republicans also disagree over how to pay for the plan they settle on. Some are looking at capping how much of employees’ health benefits can be shielded from income and payroll taxes—a broad move that would affect as many as 178 million people. Others say such caps would disrupt a system popular among employers trying to recruit top talent and employees who welcome the tax break.
“It’s going to be hard for businesses to not continue to use that,” said Rep. Phil Roe (R., Tenn.).
Republican leaders said it may ultimately fall to the president’s megaphone to quell the intraparty rebellions that show no sign of dimming.
“The president’s going to be very pivotal in this,” said Rep. Dennis Ross (R., Fla.), a member of the House GOP whip team, which is charged with rounding up votes. “He’s got to go into these districts and give air cover to these members who are weak-kneed on some of these issues.”
At least one highly experienced Republican warned recently that the outcome is far from certain.
“In the 25 years that I served in the United States Congress, Republicans never, ever, one time agreed on what a health-care proposal should look like,” former House Speaker John Boehner (R., Ohio) said at a health-care conference in Florida. “Not once.”
Write to Louise Radnofsky at firstname.lastname@example.org, Kristina Peterson at email@example.com and Stephanie Armour at firstname.lastname@example.org
More From The Wall Street Journal