WASHINGTON — President Donald Trump and conservative lawmakers in the House agreed Friday to significant changes to Medicaid that could impose work requirements on able-bodied Medicaid beneficiaries in some states and limit federal funds for the program, as Republican leaders tried to rally balking lawmakers behind legislation to repeal the Affordable Care Act.
“I want everyone to know, I’m 100 percent behind this,” Trump said at the White House, where he met with House members in the conservative Republican Study Committee. At a news conference hours later, the president predicted, “It’s going to be passed, I believe — I think substantially and pretty quickly.”
On Capitol Hill, the outlook was far less clear. The House is tentatively scheduled to vote Thursday to repeal President Barack Obama’s signature domestic achievement, exactly seven years after Obama signed it into law. As some lawmakers came out for the measure, some others — in the House and Senate — were stepping forward to oppose it.
“Fundamentally, I don’t believe this proposal provides an adequate market-based option for insurance access, nor does it address out-of-control costs,” Rep. John Katko, R-N.Y., said in a statement Friday. “Further, I am confident the proposal would harm hospitals across my district.”
The concessions to conservatives are significant — and politically risky. The Obama administration refused to allow work requirements, saying they were not consistent with the goals of Medicaid, the health program for low-income people. Several Republican governors have expressed interest in imposing such requirements on certain Medicaid beneficiaries — able-bodied adults without minor children.
“The Medicaid expansion has created a perverse incentive for states to provide benefits to able-bodied adults at the expense of the elderly, the blind and the disabled,” Rep. Gary Palmer, R-Ala., said this week. “A work requirement would help states focus their limited resources on the truly needy.”
The president and House conservatives also agreed to allow states to choose one lump-sum block grant to fund their Medicaid programs. The initial House bill would end Medicaid as an open-ended entitlement to health care, replacing that with an allotment to the states for each Medicaid beneficiary. If, instead, states accepted lump-sum payments, they could gain more control over spending and more freedom to administer the program and define eligibility and benefits.
Critics say that would restrict access to Medicaid in states with conservative governments.
It is not clear how the federal government would calculate the amount of block grants. Nor is it clear which states, if any, might accept that option.
The nonpartisan Congressional Budget Office has estimated that, under the House bill, the number of people without health insurance would be 14 million higher than expected next year and would be 24 million higher by 2026. The Medicaid adjustments could nudge that number even higher, a problem for many senators.
The one Republican senator up for re-election next year in a true swing state, Dean Heller of Nevada, said Friday that he opposed the bill in its current form. Another Republican senator, Joni Ernst of Iowa, was noncommittal.
Another likely change, Republicans said, would be to restructure the tax credits offered under the bill to help people buy private health insurance. Republican lawmakers had expressed concern that the tax credits, as originally devised by House leaders, were insufficient and could produce huge increases in premiums for some people age 50 to 64.
The changes in Medicaid provisions of the bill could help win over conservative House members who have expressed concern or outright opposition to the bill for multiple reasons. Palmer voted against the House bill in the Budget Committee on Thursday. On Friday, he emerged from the White House in favor of it.
“We’ve never had an opportunity to do anything like this,” Palmer said later. “This will be the most significant entitlement reform that we’ve seen.”
Rep. Mark Walker of North Carolina, chairman of the Republican Study Committee, said other members were on board as well.
“On balance and with the changes we agreed to in the bill’s final text, I can vote for it,” he said after the meeting in the Oval Office.
Trump’s level of engagement has been a major question mark as congressional leaders have tried to sell the proposal in the face of stinging opposition from several directions. His show of support for the House plan Friday provided a lift for House leaders, who have been on the defensive all week over their bill and the persistent conservative opposition to it.
Conservative holdouts who still have objections to the bill may reconsider if they come under more pressure from the president.
“These changes definitely strengthen our number, but also show that President Trump’s all-in now,” said the House majority whip, Rep. Steve Scalise of Louisiana, who was at the White House meeting and recounted how Trump voiced his support for the measure.
Rep. Bradley Byrne, R-Ala., said the changes in the bill were having the intended effect.
“I can tell you, from the private conversations I’m having with people, support for the bill has built dramatically over the last 24 hours,” he said Friday.
But the changes were not enough to sway the hard-right House Freedom Caucus, which reiterated its opposition on Friday. Changing the bill to win over such conservatives risks alienating more moderate members of the House and the Senate who worry that the measure could cause millions of people to lose health coverage.
The Republican governors of four states that have expanded Medicaid under the Affordable Care Act — Arkansas, Michigan, Nevada and Ohio — sent a letter to congressional leaders this week rejecting the House bill as written.
Sen. Susan Collins, R-Maine, said Thursday that she opposed the House bill, explaining that it would not do enough to help low-income older people afford insurance.
“We don’t want to in any way sacrifice coverage for people who need it the most,” she told The Portland Press Herald.
House Republican moderates may be loath to take a difficult political vote if they are convinced the measure will die in the Senate.
“If I hear one more senator tell me that this is dead on arrival, I think my head’s going to explode,” said Rep. Charlie Dent, a moderate Republican from Pennsylvania. “That certainly is not something many members of the House find very appetizing — voting for something that will go nowhere in the Senate.”
The House Democratic whip, Rep. Steny H. Hoyer of Maryland, predicted that while the bill might be approved by the House, “It will not become law.”
Under the Affordable Care Act, 31 states have expanded Medicaid, providing coverage to millions of adults. The federal government has been paying more than 90 percent of the costs for the newly eligible beneficiaries. Republicans say this has taken the program away from its original purpose.
Democrats contend that work requirements could increase the number of uninsured, limiting access to health care without significantly increasing employment.
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