Latest GOP changes target key part of current law,

Conservatives push for major changes in essential benefits.

WASHINGTON — The Trump administration and House Republican leaders were negotiating on Thursday over demands from the chamber’s most conservative faction to tear apart the Affordable Care Act — changes far more profound than those on which lawmakers had been preparing to vote.

On Wednesday, members of the House Freedom Caucus, the far-right wing of the GOP conference, said they were discussing with the White House a way to eliminate a list of 10 “essential health benefits” that the ACA requires to be covered in health plans sold to individuals and small businesses. They range from maternity care to mental health and addiction treatment to services to prevent people from getting sick and to manage chronic diseases.

By Thursday, demands from the renegade faction of conservatives had broadened significantly. The Freedom Caucus has been wielding enough power this week to derail the goal of House Speaker Paul Ryan, R-Wis., to pass the American Health Care Act, as the GOP legislation is known. According to individuals briefed on the negotiations, the Freedom Caucus was insisting on the elimination of almost the entirety of a broad and fundamental section of the ACA.

If the House leaders agree to these demands, it would mean that insurers could return to setting annual and lifetime limits on people’s coverage. Health plans could sell policies that exclude preventive care and immunizations. And they could charge more to customers based on their gender or genetic information, among other factors. These were all insurance practices that the ACA has outlawed for the past few years.

This section of the law also created the ACA’s insurance marketplaces — known as exchanges — for individuals and families that do not have access to affordable health benefits through a job.

The only parts of the section that the conservatives are willing to keep are two of the ACA’s most popular elements: letting young adults stay on parent’s health policies until they are 26, and forbidding insurers from denying coverage or charging more to customers with pre-existing medical problems.

The essential benefits list and the broader provisions that conservatives are angling to eliminate all conflict with basic ground rules that Ryan had set for the first stage of Congress’ move to repeal and replace the 2010 law with a more conservative set of health policies. Until now, the House speaker had insisted that the legislation on which the chamber votes contain only provisions that affect federal spending and thus would fit within a special budget process called reconciliation.

Under that process, legislation can pass in the Senate by a simple majority of 50 votes, rather than the typical 60 votes needed to ward off a filibuster — a significant consideration since the Senate contains 52 Republicans, while Democrats in the two chambers are solidly united against the GOP’s health plans.

Eliminating the essential benefits and other changes advocated by the Freedom Caucus almost certainly would be ruled by the Senate’s parliamentarian as not fitting within the reconciliation rules.

The other items on the list of essential benefits that could be removed are: coverage for care in doctors’ office or other outpatient settings, emergency services, hospital care, and prescription drugs. They also require coverage of rehabilitation services, laboratory tests, and pediatric services, including dental and vision care.

When the ACA passed in 2010, congressional Democrats and members of the Obama administration said these essential benefits would guarantee that people who buy coverage on their own would no longer be at risk of skimpy and inadequate insurance. Conservatives, however, have long argued that Americans should be free to buy only as much coverage as they want and that allowing bare-bones health plans would lower insurance costs.