By Sam Goldfarb, CQ Staff
House Republicans are finding it difficult to derail the health care law, and their lack of success is creating tension between leaders and rank-and-file conservatives.
The new House majority knew it would be difficult to repeal the overhaul (PL 111-148, PL 111-152) during this Congress, but many Republicans promised to at least deny federal agencies the funding needed for implementation. That is also proving to be a challenge, in part because the law’s Democratic authors insulated central provisions by underwriting them with mandatory funding outside the annual appropriations process.
GOP leaders are feeling some heat. Michele Bachmann of Minnesota and Steve King of Iowa are directing conservative ire at Speaker John A. Boehner of Ohio, who is seen as doing too little to rescind the health care law’s mandatory and discretionary funding.
The public expression of dissatisfaction has frustrated House leaders, who have strained to show their commitment to conservative causes. It also comes at an awkward moment as Republican leaders try to prepare the rank-and-file to accept inevitable compromises with Senate Democrats and President Obama on spending levels for the remainder of fiscal 2011.
Boehner’s difficulties were highlighted two weeks ago when 54 Republicans opposed a stopgap spending measure (PL 112-6) to fund the government through April 8. Conservatives said their concern about leadership efforts to weaken the health care law were a major reason for the dissenting votes.
King has been trying for months to draw attention to the mandatory spending in the health care law, but the issue gained momentum only recently when a dollar figure was attached to that spending. During a March 6 appearance on NBC’s “Meet the Press,” Bachmann said the law provides $105 billion in “hidden” appropriations over the next decade, pointing to a February Congressional Research Service (CRS) report. The number was quickly picked up by conservative bloggers, and Fox News created an online calculator intended to allow taxpayers to determine how much of the $105 billion they were paying.
Explaining his vote against the latest stopgap measure, Ralph M. Hall, R-Texas, said his constituents are worried about “the $105 billion that was considered Obama money.” He added, “I’m for knocking anything that Obama has out if you have a shot at it, and we had a shot at it.”
The House has passed three spending measures this year, all of which cut only discretionary accounts. Republican leaders have argued in private sessions that appropriations bills are not the place to change mandatory spending.
Mandatory spending “is not under the jurisdiction or purview of the Appropriations Committee,” a House Republican aide said last week. Tackling both types of spending in a continuing resolution would be “completely contrary to democratic processes and rules of the House,” the aide said.
But advocates of cutting mandatory spending offer technical arguments and emotional appeals. They acknowledge that House rules prohibit using appropriations bills to make changes in mandatory spending, but point out that those rules can be waived by the Rules Committee when continuing resolutions are brought to the floor, leaving only proposed amendments that would affect mandatory spending subject to procedural objections.
Congress has sometimes used appropriations bills to reduce mandatory spending, although not on a large scale. The maneuver is common enough that it has its own acronym — CHIMPS, for “changes in mandatory program spending.”
From fiscal 2003 through fiscal 2010, appropriators cut mandatory agricultural spending programs by $7.5 billion, according to the CRS. Those relatively modest reductions were typically offset by increases in discretionary spending.
King calls the distinction between mandatory and discretionary health care law spending “a straw man argument” offered by GOP leaders who are eager for an agreement with Democrats on fiscal 2011 spending and “don’t want the confrontation.”
Untying the Knot
A year after the health care overhaul became law, some lawmakers are only now confronting its complexity. The $105 billion is just a portion of the law’s net cost. The Congressional Budget Office estimates the cost of the law will surpass $900 billion over 10 years, all of which the law offsets with revenue increases and spending cuts.
The roughly $105 billion is directed toward specific programs, which have been detailed in a series of CRS reports. But the bulk of the mandatory spending comes from an expansion of access to Medicaid and its subsidies to help some people to meet the requirement to participate in new health insurance exchanges.
The law also authorizes discretionary spending for new and established programs, pushing the cost up another $100 billion or so, depending on the actions of appropriators. Some programs, such as community health centers, are tapped to receive both mandatory and discretionary money.
Democrats are generally cautious about explaining their distribution of health care funds, but it is clear to most who have looked at that question that the more controversial and crucial programs were provided with the more reliable mandatory spending.
The law provides $5 billion in mandatory spending to establish temporary high-risk pools for individuals with preexisting conditions. It also provides funding for an advisory board that is supposed to control the growth of Medicare spending.
But a medical malpractice demonstration project intended to appeal to Republicans is funded by annual discretionary appropriations.
Under normal circumstances, the discretionary programs in the health care law “would probably have bipartisan support,” said G. William Hoagland, a former Republican Senate Budget Committee aide who is now vice president for public policy at Cigna Corp., a health insurer.
Because Congress has not cleared any of the fiscal 2011 spending bills, no programs newly authorized by the health care overhaul have been funded. For Republicans, that is an unintended benefit of the budget standoff.
The overhaul also reauthorized existing programs, including the National Health Service Corps and a program that benefits rural hospitals. The fiscal 2011 spending measure (HR 1) passed by the House would cut those programs, but Republicans have not proposed their elimination.
For example, the Republican-written spending bill would offset $1 billion in mandatory spending for community health centers — first established in 1962 — with a corresponding cut of $1 billion in discretionary spending. But it would still allocate $1.2 billion in discretionary funds for health centers, effectively leaving the spending level.
An exasperated King has compared the health care legislation to the Gordian Knot. King and some other conservatives reject the leadership’s call for tackling mandatory health care spending outside the appropriations process, contending that restricting discretionary spending for health care law implementation is insufficient.
Democrats strongly oppose including any restrictions in any spending bill, but GOP leaders continue to promise that the law can be weakened. “We’re going to try everything we can to again slow this thing down, to defund it,” House Majority Leader Eric Cantor, R-Va., said last week.
A version of this article appeared in the March 29, 2011 print issue of CQ Today
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