Congressional Republicans are once again scrutinizing Obamacare as they search for ways to offset the cost of President Donald Trump’s legislative agenda.

The House is weighing how to reduce the generous subsidies that led 41 states to expand Medicaid through former President Barack Obama’s signature healthcare law.

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The leading proposal, a “per capita” cap on how much states are reimbursed, is a far cry from the failed efforts at repeal in Trump’s first term. But the renewed focus reflects how Republicans are still trying to chip away at the law 15 years after it first passed.

Under the plan, the federal government would pay states a set amount per Medicaid enrollee rather than an open-ended percentage, forcing states to shoulder more of the cost for the expansion population.

Congress could also lower the 90% reimbursement under Obamacare, a higher rate than the 50% to 83% doled out for traditional Medicaid recipients. But Republicans want to avoid that scenario since nine states have “trigger” laws that would roll back the expansion entirely.

The politics over Obamacare are not altogether different from eight years ago, when the late Sen. John McCain dramatically cast the deciding vote against “skinny repeal.”

Most congressional Republicans view the Medicaid expansion, which covers certain low-income adults, as straying from the original purpose of the program: to insure vulnerable populations such as children and the disabled. But a segment of centrists who represent purple or blue states won’t vote for anything that cuts benefits.

Any change to subsidies risks millions losing their coverage as state legislatures decide how to, or if they can, absorb the larger healthcare tab.

With narrow GOP control of the House and Senate, it’s possible Obamacare escapes unscathed once again. This time, Trump is also opposed to touching Medicaid beyond the vague buckets of “waste, fraud, and abuse.”

Yet there is, for now, a serious effort to revisit the program as fiscal hawks demand $1.5 trillion in cost savings to pay for Trump’s tax, border, and energy agenda. House Majority Leader Steve Scalise (R-LA) told reporters Thursday that Republicans were discussing “final details,” such as the per capita caps, with the White House.

The proposal also came up this week in closed-door meetings of the Energy and Commerce Committee, which has jurisdiction over Medicaid.

Obamacare is just one element of a larger discussion about Medicaid. Republicans have been floating a menu of options such as work requirements and more frequent eligibility checks, low-hanging fruit that could yield $100 billion or more in savings, according to the Committee for a Responsible Federal Budget.

From there, the conversation begins to divide Republicans. One proposal – lowering the 50% floor on state reimbursements – is already off the table, according to Rep. Nicole Malliotakis (R-NY). 

New York, her home state, is one of 10 that would fall below 50% based on formulas that calculate reimbursement based on average per capita income.

“We’ve gotten that commitment already. The speaker’s been clear. The president’s been clear, and we’ve been clear that we’re not going to support a bill that lowers the reimbursement rate from 50% for New York state,” Malliotakis told the Washington Examiner.

Republicans also believe the maximum reimbursement rate should be lowered — if not for traditional recipients, then at least for the Obamacare population. But the same fear of a state rollback in benefits has centrists drawing red lines.

“The threshold question that I ask every time somebody says, ‘Hey, what about this about Medicaid? What about that about Medicaid?’ Does it throw people intended to be on the program off the program? If the answer is yes, I’m likely to not support it,” said Rep. Nick LaLota (R-NY).

The New York delegation and blue state Republicans at large will prove decisive to what makes it through the House, where Johnson controls a three-vote majority. Both LaLota and Malliotakis are separately causing leadership heartburn with a push to expand SALT, a tax deduction that disproportionately helps higher-income earners. 

But Johnson must also satisfy the ranks of fiscal conservatives who extracted the $1.5 trillion in spending cuts in the first place, $880 billion of which must come from the Energy and Commerce Committee.

On Thursday, that panel scrapped plans to sign off on its portion of the bill next week, raising the likelihood that Johnson will be unable to pass Trump’s agenda before a self-imposed deadline of Memorial Day.

Republicans did have some success in Trump’s first term taking a scalpel to Obamacare. Months after the failed Senate vote, they were able to repeal the individual mandate by zeroing out the penalty as part of Trump’s 2017 tax law.

Yet full repeal is no longer the rallying cry it was in the Tea Party era, and Trump largely eschewed the issue of healthcare on the campaign trail last year. When it did come up at his debate against then-Vice President Kamala Harris, she mocked him for saying he had “concepts of a plan” to replace Obamacare.

In fact, safety net programs are today one point of friction between Trump and fiscal hawks on Capitol Hill. He still knocks the healthcare law as a failure, boasting that he could come up with something better. But in a reversal of roles, Trump could be the one who ends up protecting it from the more withering Medicaid cuts if he rejects the House’s “per capita” proposal.

On Thursday, Rep. Chip Roy (R-TX), the Freedom Caucus policy chairman, released a “Dear Colleague” letter urging significant reforms to address the “Medicaid crisis.”

He singled out Obamacare in particular while accusing states of “money laundering” to earn even more than the 90% reimbursement offered to the expansion population.

Rep. Byron Donalds (R-FL), another Freedom Caucus member, called Medicare expansion the “original flaw” of Obamacare. Florida, where Donalds is running for governor, is one of the few states that did not expand the program.

“I guess my question is, why are we treating able-bodied adults better than poor children?” he said of the 90% reimbursement.

For states that have expanded Medicaid, the Capitol Hill debate has set local lawmakers on edge. Earlier this month, 12 GOP legislators in Utah penned an op-ed asking Congress to reject “indiscriminate large reductions” to the welfare program.

In Minnesota, 27 Republicans sent a letter to their congressional delegation in Washington warning of the possible impact to beneficiaries if the changes are not “modest, manageable and accompanied by extreme flexibility.”

In an interview, state Sen. Jim Abeler, the lead signatory on the Minnesota letter, said his preference would be for the federal government to block-grant the entire Medicaid program, even if it meant a small cut in dollars.

“We’re hamstrung by a Byzantine web of federal regulations, many of which make no sense,” said Abeler, a chiropractor and senior Republican on the state Senate’s Human Services Committee.

“If they simply block-granted the amount of money that we get now and froze it for two years, that would do an incredible benefit to the budget,” he added. “And then the states would be allowed to decide what they really want to do.”

Abeler said he and his GOP colleagues sent another letter to Congress back in 2017 when Republicans were considering similar Medicaid proposals like the per capita cap.

Other state Republicans have expressed their concerns in private, with Sen. Shelley Moore Capito (R-WV) recounting conversations she’s had with the governor and legislators in her state of West Virginia in recent months.

“I think the main concern is delivering service, delivering healthcare, but obviously the cost shift is a concern,” she said.

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The high share of Medicaid recipients in red states like West Virginia has complicated Trump’s agenda through the Senate as well. Sen. Josh Hawley (R-MO), in particular, has threatened to vote against any bill that reduces benefits, as have centrists such as Sen. Lisa Murkowski (R-AK).

“Eh, it sounds to me like a recipe for cutting benefits in the states,” Hawley said of proposals to shift the Medicaid cost burden onto states. “I’d be skeptical of that.”

Rachel Schilke and Lauren Green contributed to this report.