PHILADELPHIA - Republican lawmakers aired sharp concerns about their party's quick push to repeal the Affordable Care Act inside a closed-door meeting Thursday, according to a recording of the session obtained by The Washington Post.
The recording reveals a GOP that appears to be filled with doubts about how to make good on a long-standing promise to get rid of the ACA without explicit guidance from President Donald Trump or his administration.
Senators and House members expressed a range of concerns about the task ahead: how to prepare a replacement plan that can be ready to launch at the time of repeal; how to avoid deep damage to the health insurance market; how to keep premiums affordable for middle-class families; even how to avoid the political consequences of defunding Planned Parenthood, the women's health-care organization, as many Republicans hope to do with the repeal of the ACA.
"We'd better be sure that we're prepared to live with the market we've created [with repeal]," said Rep. Tom McClintock, R-Calif. "That's going to be called Trumpcare. Republicans will own that lock, stock and barrel, and we'll be judged in the election less than two years away."
Recordings of closed sessions at the Republican policy retreat in Philadelphia this week were sent late Thursday to The Washington Post and several other news outlets from an anonymous email address. The remarks of all lawmakers quoted in this story were confirmed by their offices or by the lawmakers themselves.
"Our goal, in my opinion, should be not a quick fix. We can do it rapidly - but not a quick fix," said Sen. Lamar Alexander, R-Tenn. "We want a long-term solution that lowers costs."
Sen. Rob Portman, R-Ohio, warned his colleagues that the estimated budget savings from passing the Obamacare repeal bill - which could approach a half-trillion dollars - is needed to fund the costs of setting up a replacement. "This is going to be what we'll need to be able to move to that transition," he said.
Rep. Pete Sessions, R-Texas, worried that one idea floated by Republicans - a refundable tax credit - won't work for middle-class families that can't afford to prepay their premiums and wait for a tax refund.
And Rep. John Faso, R-N.Y., a freshman congressman from the Hudson Valley, warned strongly against using the repeal of the ACA to also defund Planned Parenthood. "We are just walking into a gigantic political trap if we go down this path of sticking Planned Parenthood in the health insurance bill," he said. "If you want to do it somewhere else, I have no problem, but I think we are creating a political minefield for ourselves - House and Senate."
The concerns of rank-and-file members appeared to be at odds with key congressional leaders and Andrew Bremberg, a top domestic policy adviser to President Trump, who laid out their plans to repeal the ACA using a fast-track legislative process and Trump administration executive actions. However, these leaders acknowledged in Thursday's meeting, as they have before, that the law known as Obamacare cannot be fully undone - or replaced - without Democratic cooperation.
That and other aspects of the unfinished GOP plan prompted several wary members to urge their leaders to move more deliberately - even as the Trump administration appears to be moving ahead with repeal. On Thursday, the White House ordered federal health officials to immediately halt all advertising and other outreach activities for the critical final days in which Americans can sign up for 2017 health coverage through Affordable Care Act marketplaces.
Of particular concern to some Republican lawmakers was the plan to use the budget reconciliation process - which requires only a simple majority vote - to repeal the existing law, while still needing a filibuster-proof vote of 60 in the Senate to enact a replacement.
"The fact is, we cannot repeal Obamacare through reconciliation," said McClintock. "We need to understand exactly, what does that reconciliation market look like? And I haven't heard the answer yet."
Several key policy areas appeared unsettled. While the chairmen of several key committees sketched out various proposals, they did not have a clear plan on how to keep markets viable while also requiring insurers to cover everyone who seeks insurance.
They are also still wrestling with whether the ACA's taxes can be immediately repealed, a priority for many conservatives, or whether that revenue will be needed to fund a transition period. And there seems to be little consensus on whether to pursue a major overhaul of Medicaid - converting it from an open-ended entitlement to a fixed block grant.
Many of the concerns aired Thursday were more political than policy-oriented. Faso's remarks generated tepid applause. House Speaker Paul Ryan, R-Wis., said this month that he expects the House to pursue Planned Parenthood's defunding in the reconciliation bill.
One Republican lawmaker asked panelists a "simple question:" Will states have the ability to maintain the expanded Medicaid rolls provided for under the ACA?
"These are decisions we have to make," replied another. "That's why we are here today."
Tom MacArthur, R-N.J., also worried that the plans under GOP consideration could eviscerate coverage for the roughly 20 million Americans now covered through state and federal marketplaces as well as those covered under Medicaid expansion: "We're telling those people that we're not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them."
Those expressing qualms included some of the top congressional leaders who are in line to draft the health care legislation.
Alexander, for one, is chairman of the Senate Health, Education, Labor and Pensions Committee.
Ryan and other leaders have said they intend to pursue a piecemeal approach, following the reconcilation bill with smaller bills that address discreet aspects of reform.
Bremberg, chairman of Trump's domestic policy council, offered little detail in the session about particular executive actions the Trump administration intended to take or what legislative proposals the new president favors.
Instead, he pointed to the executive order Trump signed last week, his first, as proof of his commitment to undoing Obamacare's mandates and said his choice of Rep. Tom Price, R-Ga., to be his Health and Human Services secretary "should speak volumes to people trying to understand what he's hoping to achieve."
"This is not a technocrat," Bremberg said. "This is an experienced, compassionate doctor who has experienced the health care system firsthand and who has been a leader here in Washington trying to address the policy reforms that need to take place. Having both of those in a secretary is going to be very important and very powerful."
The Trump administration did not immediately respond to a request for comment on Bremberg's remarks.
Faso warned that by defunding Planned Parenthood in the reconciliation bill, "we are arming our enemy in this debate."
"To me, us taking retribution on Planned Parenthood is kind of morally akin to what Lois Lerner and Obama and the IRS did against tea party groups," he said, a reference to accusations that the Internal Revenue Service improperly targeted conservative political groups for audits.
Faso continued: "Health insurance is going to be tough enough for us to deal with without having millions of people on social media come to Planned Parenthood's defense and sending hundreds of thousands of new donors to the Democratic Senate and Democratic congressional campaign committees. So I would just urge us to rethink this."
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The Washington Post's Robert Costa, Juliet Eilperin and Paul Kane contributed to this report.