Paul Ryan open to ‘fine-tuning’ of Republican health plan

House Speaker Paul D. Ryan signaled Wednesday that he is open to “fine-tuning” the Republican health care bill as he and President Trump try to win back conservatives — and risk alienating even more moderates in the Senate who say the legislation is already kicking people out of coverage.

The Trump administration reported that sign-ups dropped during the most recent Obamacare enrollment period, signaling that the law Democrats wrote in 2010 continues to struggle. Sen. Lindsey Graham said Republicans should just wait and let it collapse and that the politically smart move is to make Democrats take the blame.

But Mr. Ryan has insisted on rescuing Americans from the Affordable Care Act with consensus reforms that won support during last year’s campaign.

He said the White House is fully on board with the plan, though leadership is still accepting feedback and mulling changes — a sign that the plan might not have the support it needs to gather enough votes on the floor and head to the Senate, where skeptical Republicans are picking apart the plan.

Mr. Ryan declined to say whether the bill would hit the floor next week, as initially planned. He said it’s up to the majority leader and that a snowstorm set them back a bit.

Mr. Trump said the House plan meets the requirements he laid out in his first major address to Congress, though he didn’t attack Republican holdouts during a rally in Nashville, Tennessee, saying the party will “arbitrate” its differences and “get something done.”

Instead, he blasted Democrats for standing by a flailing law and boxing in his reform plans.

“Remember, folks, Obamacare is gone. It’s not working,” he said. “What we can’t do is be intimidated by attacks from Democrats in Congress who broke the system in the first place and didn’t trust you to make your own decisions.”

The leaders appear to be making some headway. The Republican Study Committee, an influential bloc of conservatives, emerged from a Capitol Hill meeting with Vice President Mike Pence saying they are optimistic about winning votes to reel in Obamacare’s vast expansion of Medicaid sooner, while requiring poor, able-bodied adults in the program to work, volunteer or attend school to obtain benefits.

“I think most guys would have to walk away feeling optimistic about the process,” RSC Chairman Mark Walker, North Carolina Republican, said after the meeting.

Rep. Charles W. Dent, Pennsylvania Republican and co-chairman of the centrist Tuesday Group, said freezing Medicaid expansion in 2018 instead of 2020 “would be a nonstarter and very problematic for many of our members.”

The next test will come Thursday when the House Budget Committee debates the bill.

Republicans have been reeling after the Congressional Budget Office estimated that it would save $300 billion but result in 24 million fewer people holding insurance a decade from now — an eye-popping report that is already spooking some centrist Republicans while making conservatives even more certain that the plan amounts to an expensive entitlement.

Rep. Dave Brat, Virginia Republican and a member of the Budget Committee, told Politico that he plans to vote “no,” meaning the plan could stall if three other Republicans join him and every Democrat on the panel rejects the bill.

Mr. Brat is a member of the House Freedom Caucus, which has blasted the plan alongside three Senate Republicans — Ted Cruz of Texas, Rand Paul of Kentucky and Mike Lee of Utah. They say Republicans should focus on repeal first and push a replacement that drives down premiums.

“If we take this opportunity and blow it, we will rightly be considered a laughingstock,” Mr. Cruz told tea party activists who rallied outside the Capitol on Wednesday.

Mr. Paul gave copies of Mr. Trump’s book “The Art of the Deal” to the Freedom Caucus late Wednesday. He said the health care plan is in “pre-negotiation” and the real talks will begin “when leadership discovers there’s not enough votes to pass their bill.”

Rep. Mark Meadows, the North Carolina Republican who leads the Freedom Caucus, said he has the votes to block the House bill in its current form.

But Republicans say the reconciliation process constrains what they can do legislatively on the first try. Step two would involve regulatory changes, and step three would involve more legislation that would have to face an expected Democrat-led filibuster in the Senate.

Majority Leader Kevin McCarthy, California Republican, said the House will start moving some of those bills next week, including one that would crack down on frivolous medical lawsuits and let small businesses pool together when buying insurance.

Some Senate Republicans said the House should slow down and develop a plan with broad party appeal, since Democrats will never help Republicans with reforms that are supposed to come in the third phase.

“Here’s what I hope the president would do. Try to get a good bill. If you can’t, let Obamacare collapse and challenge the Democrats to help him fix a problem they created,” Mr. Graham, South Carolina Republican, told NBC’s “Today” program.

The administration said 12.2 million selected coverage for this year on the web-based exchanges set up under the Affordable Care Act, compared with 12.7 million during last year’s open enrollment season.

That’s far short of the 13.8 million that Obama administration officials had hoped to get in order to place their signature law on firmer economic footing.

Democrats accused Mr. Trump of pulling crucial HealthCare.gov ads to sabotage enrollment numbers, saying things were trending upward under Mr. Obama in January.

They’ve said that while Obamacare is failing in some places, the solution is to expand the federal footprint in health care through extra-generous subsidies and to add a government-run “public option” to compete with private plans in the marketplace.

Republicans have rejected those ideas as a costly attempt to load on “more Obamacare.”

Even as conservatives seek to push the Republican bill to the right, centrists say the plan is already too draconian. Rep. Ileana Ros-Lehtinen, Florida Republican, said she will not vote for a plan that slashes coverage and funds for the poor and elderly.

“Now that we have a score, we can incorporate feedback to improve this bill, to refine this bill — and those kinds of conversations are occurring between the White House, the House, and the Senate and our members,” Mr. Ryan said.

“The bottom line,” he said, “is we made a promise to repeal and replace Obamacare, and we’re going to keep our word.”