A key element of healthcare reform that President Trump had repeatedly promised his administration would accomplish was noticeably absent from the Obamacare replacement bill rolled out by House Republicans this week.
Virtually every time the president was asked to specify which portions of Obamacare he would amend or repeal during the course of the campaign, Trump pointed to restrictions on interstate insurance sales. An interstate individual health insurance market would make coverage more affordable by boosting competition among insurers, candidate Trump repeatedly said.
"You're going to have plans that are so good because we're going to have some competition," Trump said last October during a lengthy segment on Obamacare in the second presidential debate.
"We have to get rid of the lines around the state," he told the moderators. "Artificial lines, where we stop insurance companies from coming in and competing because they want, and President Obama and whoever was working on it, they want to leave those lines because that gives the insurance companies essentially monopolies."
But it turns out, that is one provision that is unlikely to become law. It almost certainly can't be passed in the Senate, since it will be included in a second Obamacare replacement bill that will not run under "reconciliation" rules and that therefore will require 60 votes in the Senate. With only 52 Republican senators, passage would seem unlikely.
It may seem strange that the White House would exclude a provision to eliminate such restrictions during the first phase of their legislative effort to repeal and replace the Affordable Care Act. Some worry that waiting to restore interstate insurance sales in phase two or three of the legislative process might jeopardize its chance of passing.
"We obviously would have liked to have included this, but it just wasn't in the cards," one congressional GOP staffer told the Washington Examiner.
The staffer said there was an understanding during negotiations with the Senate that repealing regulations that prohibit interstate insurance sales was "not something that could fly under their rules" with respect to "reconciliation" bills.
"Purchasing insurance across state lines is a provision outside the scope of reconciliation, therefore it was not included in this part of the process," said Doug Andres, a spokesman for House Speaker Paul Ryan.
Procedural rules enforced by the Senate parliamentarian forbid lawmakers from using reconciliation to amend laws that have not previously been scored by the Congressional Budget Office, or to pass legislation unrelated to the budget. The process also benefits the party in power due to the fact that reconciliation bills are filibuster-proof, so the majority only needs 51 Senate votes to pass a reconciliation bill.
Trump has assured conservative supporters and skeptics of the current legislation that "getting rid of state lines ... will be in phase two and three of the healthcare rollout." Health and Human Services Secretary Tom Price repeated those assurances during meetings with lawmakers.
But conservative leaders who have cast the Republican healthcare bill as "Obamacare lite" or "Ryancare" said the administration hasn't offered a "full-throated argument" as to why they declined to include the provision on interstate insurance sales in the bill revealed on Monday.
"They don't want to take the risk that the Senate parliamentarian knocks it out," said one source who attended a White House listening session on healthcare earlier this week.
"But the parliamentarian is like a staff adviser," the source said, noting that meeting attendees "made that point" during their sit-down with Trump and Vice President Mike Pence.
Trump told conservatives in Wednesday's meeting that House Republicans could unveil a companion healthcare bill as early as next week, signaling that he hopes to move rapidly to reduce regulations on health insurance markets like those that bar interstate insurance sales.
"I think they're in sell mode right now but the president and his staff are working to address concerns about the tax credits, failure to repeal regulations and the no competition across state lines," the source said.
"But at this point, anything major is going to require the support of eight [Senate] Democrats," they added, reiterating that phases two and three would likely follow reconciliation.