Republicans led by Vice President Mike Pence pushed to revive a moribund health care bill on Tuesday, meeting late into the night with key lawmakers eager to build new GOP consensus to repeal the Affordable Care Act.
Pence spent much of Tuesday on Capitol Hill meeting with key groups of lawmakers, as well as with House Speaker Paul Ryan, R-Wis., a day after visiting separately with conservative hard-liners and moderates to gauge the potential for a revamped version of legislation that collapsed last month.
The crux of the new proposal would be to allow states to seek exemptions from certain mandates established under the Affordable Care Act - including a requirement that insurers cover 10 "essential health benefits" as well as a prohibition on charging those with preexisting medical conditions more than the healthy.
While the largely behind-the-scenes effort generated optimistic talk, no clear path has emerged toward House passage of the Republican bill. On Tuesday evening, key players said they were still waiting to see new proposals in writing, and some lawmakers said they were wary of rushing the process.
"There is a value sometimes to the vetting process," said Rep. Mark Sanford, R-S.C., a member of the hard-right House Freedom Caucus, a group targeted by President Donald Trump last week for its opposition to the bill. "That having been said, we'll see what comes our way."
Pence and other Trump administration officials attended a meeting late Tuesday in the Capitol with member of key House GOP factions, including the Freedom Caucus. But the meeting broke after two hours without a clear resolution, though several participants said there was progress and plan to continue the discussions on Wednesday.
Rep. Mark Meadows, R-N.C., the Freedom Caucus chairman, said before the meeting that his group was still seeking broad relief from the ACA's insurance mandates. Afterward, he said there was debate but no real accord on that contentious issue.
"There were no agreements tonight, and no agreements in principle, and certainly no agreements in terms of a foundation," he said. "There was a general agreement that the progress we're making is certainly progress, and there are good discussions, but understanding that there's a whole lot of things that we have to work out."
Others - both Republicans and Democrats - objected to the idea of undoing protections for people with preexisting conditions. That ACA requirement, known as "community rating," prohibits insurers from segregating healthy subscribers from sick ones or charging the latter higher prices. Instead, they may vary their prices based only on age, geographic location and tobacco use, allowing the premiums paid by the healthy to subsidize the sick.
Sen. Patty Murray (Wash.), the ranking Democrat on the Senate Health, Education, Labor and Pensions Committee, said in a statement that the proposal would "give power back to the insurance companies, increase costs, and undermine care for people with preexisting conditions."
Rep. Tom Reed, R-N.Y., a member of the Ways and Means Committee, called the provision "a very significant reform" that he was concerned about rolling back, even if states would have to be granted a waiver.
The new proposal could also allow states to strip back other mandates, including requirements that insurers provide coverage for mental-health care, substance abuse treatment, maternity care and prescription drugs.
The changes were largely calibrated to win over the hard-liners in the Freedom Caucus, who blame the mandates for driving up insurance premiums. But the proposal also takes into account the qualms of moderates who are wary of undermining the ACA's key reforms by requiring states to apply for waivers and to justify why insurers should not be required to provide certain coverage.
Those moderates helped defeat the original version of the American Health Care Act nearly two weeks ago, largely out of concern over a similar provision governing essential health benefits. And advocates of the new proposal appeared to be making little headway Tuesday.
"While we haven't picked up any votes yet, this concept is already showing signs of losing a ton of them," said a House Republican leadership aide, who requested anonymity to speak more candidly.
Ryan said Tuesday that the talks were in the "conceptual stages" and did not commit to a timeline for resolving the differences that sank the bill last month. "It's important that we don't just win the votes of one caucus or one group," he said.
Pence sounded a similarly nonspecific note, telling a gathering of business executives at the White House that he and President Trump "remain confident" that Congress would repeal and replace the ACA.
White House press secretary Sean Spicer offered no timetable either, saying only that administration officials would continue meeting with lawmakers in hopes of advancing the bill.
"The president would like to see this done if we can get a deal," Spicer said. "I'm not going to raise expectations, but I think that there are more and more people coming to the table with more and more ideas about how to grow that vote."
Though aides said Trump has been in touch with both House and Senate members in recent days, he was playing a much less visible role in deliberations than in the days leading up to the aborted vote. Aides said that was partly because of a string of visits this week from three world leaders.
Pence, White House Chief of Staff Reince Priebus and budget director Mick Mulvaney began the two-day push to revive the repeal effort late Monday, with a trip to Capitol Hill to attend a Freedom Caucus meeting. Meadows said they offered a "solid idea" in that meeting to build a potential compromise around.
But both Freedom Caucus members and moderates emerged from a Tuesday morning House GOP conference lacking clarity on the path forward.
"Right now there are really just discussions, there's no deal in the works, there's been no deal on anything," said Rep. Justin Amash, R-Mich., a Freedom Caucus member.
Rep. Steve Womack, R-Ark., a House leadership ally, said he didn't get the sense that a compromise was near.
"I didn't get any vibe this morning of 'hold the phone, we may be close to a deal here,' " he said. "There's no white smoke coming out of any leadership office that I'm seeing."
Meadows said late Monday that he expected that the proposal would be drafted into legislative text within 24 hours, but he said after the Tuesday-night meeting that no such text had been offered by the White House or congressional leaders, leaving "unanswered questions" for hard-liners.
While addressing reporters, Spicer was asked whether a deal that rolled back protections for preexisting conditions would violate a campaign pledge by Trump. "We're not there yet," he said. "We're having discussions."
Two other moderate House members also said they remained opposed: Rep. Frank LoBiando, R-N.J., tweeted that he had "seen nothing in terms of reported possible changes to American Health Care Act warranting reconsideration." And Rep. Leonard Lance, R-N.J., said changes to community rating would undermine protections for those with preexisting conditions.
On the flip side, it was unclear just how many Freedom Caucus members could be swayed with the softened provision to give states the option of requesting exemptions to some of the ACA's mandates.
"I don't think that a long-term solution consists of allowing states to ask the federal government for waivers, because presidents change," said Rep. Mo Brooks, R-Ala. "States ought to have as a matter of right the ability to determine what insurance policies for their citizens should contain."
A health care industry official argued that the proposed changes to the bill appear to leave in place most of the core problems with the original bill and exacerbate others by making changes that would effectively make insurance either too expensive or too skimpy for sick people.
"To put it simply, this is making a bad bill worse," said the industry official, who spoke on the condition of anonymity in order to speak frankly. The official added that his industry is waiting to see the details of the revised bill before weighing in publicly: "You don't want to rain on a parade until you know it's headed into town."
As part of his push to revive the bill, Pence also arranged on short notice a meeting and phone call Tuesday with some leading conservative activists who have been skeptical of the health care proposals floated so far.
The group included Marjorie Dannenfelser, president of the Susan B. Anthony List; Jim DeMint, president of the Heritage Foundation; Grover Norquist, president of Americans for Tax Reform; Tim Phillips, president of Americans for Prosperity; and Matt Schlapp, chairman of the American Conservative Union.
The flurry of activity Monday and Tuesday raised some hopes that the closely watched legislation could be revived and passed through the House quickly. But with lawmakers ready to leave town Thursday for a two-week Easter recess, others questioned the rush.
"A lot of people would love to get this done this week - kind of unrealistic given all the changes that are being discussed," said Rep. Ken Buck, R-Colo., a Freedom Caucus member who supported the original version of the AHCA. "Some people want to come back next week - kind of unrealistic given all of the plans everybody has in their district for next week. And then the most realistic thing, I think, is to try and get something done when we get back."
Meadows said Tuesday night that it was "premature" to rule out a vote this week but also made clear no deal was at hand and there are "no real discussions" about potentially keeping the House in session to push the bill through.
Ryan has taken a less direct role in the renewed negotiations, aides involved in the discussions say, out of a desire to let the various GOP factions work matters out on their own timetable rather than forcing a deal that could backfire.
Trump took aim at the Freedom Caucus in tweets Thursday, pledging to "fight them" at the polls in the 2018 midterms. He remained active on Twitter over the weekend, suggesting that the situation was still fluid - and that he is looking at ways to move forward with the help of either moderate Democrats or conservative Republicans.
The president also played a round of golf Sunday with Sen. Rand Paul, R-Ky., the libertarian-oriented former presidential candidate who has been a sharp critic of the House bill and celebrated its failure less than two weeks before.