Why the House put off its vote on Trumpcare

President Donald Trump, House Speaker Paul Ryan, and their allies attempted to resuscitate their health care bill Thursday in heated negotiations with Republican lawmakers. But after it became clear there were not enough House Republicans willing to support the bill, the vote, originally planned for Thursday evening, was postponed.

If more than 22 Republicans vote “no,” the bill won’t pass. As of Thursday afternoon, the New York Times reported, 32 were currently committed to voting “no” and 15 were uncommitted or leaning “no.”

Trump met at the White House Thursday with about 40 members of the extremely conservative House Freedom Caucus, which has expressed several misgivings with the bill. At the meeting, lawmakers argued that a rule requiring that health insurers cover 10 types of coverage labeled “essential health benefits” by the Affordable Care Act needed to be eliminated, and that doing so would bring down premiums.

That rule was a sticking point “in a lot of cases,” Press Secretary Sean Spicer later told reporters. And not just with ultra-conservative lawmakers; individual members of the Tuesday Group, an informal band of several dozen relatively moderate Republicans, have said they want to keep some of the essential health benefits in place. The group met with House leadership this morning and with Trump this afternoon.

The Affordable Care Act’s essential health benefits are:

• Emergency services
• Outpatient services
• Hospitalization, including overnight stays and surgeries
• Laboratory services
• Prescription drugs
• Pediatric services
• Preventive and wellness services, like screenings and shots
• Rehabilitative services
• Mental health and addiction services
• Pregnancy and childbirth care

Even if the entire Freedom Caucus votes in favor of the bill, the votes of some members of the Tuesday Group will be needed to pass the bill, and those votes are hardly in the bag.

“It gives great flexibility for insurance companies to design policies to hit any price point now that you want,” Karen Pollitz, a fellow at the nonpartisan health care research organization Kaiser Family Foundation, said of the possibility of eliminating the essential health benefit rule. “They just won’t necessarily cover what you need.”

Policies that are more comprehensive would be much pricier, Pollitz said, because they would likely be purchased by people who urgently need that extra coverage — and not other people. Instead, younger and healthier people will tend to gravitate to cheaper policies that are less comprehensive, since they may not see a need to pay for more.

Plus, Pollitz said, some benefits may not be covered by anyone at all, because health insurers won’t “want to cover a benefit that the competition doesn’t cover, if that’s going to attract an expensive population.”

Before the Affordable Care Act fully took effect in 2014, for instance, several states did not mandate that insurers provide maternity coverage. In those states, only 6 percent of all individual plans available to a 30-year-old woman offered that coverage, according to a National Women’s Law Center report.

It’s still unclear what a change in federal law would mean for states that do require certain coverage.

Trump believes that the provision preventing insurers from discriminating against people with pre-existing conditions “needs to stay in there,” Spicer said. Members of the Tuesday Group agree. But even if that provision remains, it could end up being all but meaningless in some cases if there are no plans that cover care for certain conditions.

“Before the [Affordable Care Act], health insurance coverage under federal law was defined as anything a health insurance company sells,” Pollitz said. “Now, health insurance has to be major medical coverage. So if that goes away, health insurance becomes sort of a very broad term, and you could have anything from a policy that covers a toothbrush to major medical coverage, at least in theory.”