‘Trumpcare’ faces its make or break day

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House Speaker Paul Ryan and President Donald Trump Win McNamee/Getty images

The American Health Care Act, the GOP’s bill to repeal and replace Obamacare, faces its biggest test yet on Thursday as members of the House of Representatives are expected to vote on the legislation.

Despite a push from President Donald Trump and administration officials, Republicans from both the conservative and moderate wings of the party have come out against the bill, saying it either does not go far enough in its repeal of Obamacare or does not make enough improvements.

According to the New York Times’ tracker of House members’ public statements, 29 Republicans have said they will vote against the bill. That is above the 23 defections from the GOP that would sink the bill.

Given the precarious standing of the AHCA as it heads into the vote, the White House and GOP leaders have been engaging in last-minute discussions with House members in an attempt to win them over on the bill, but it remains unclear whether the bill will pass.

Negotiations with conservatives

The largest bloc that must be won over for Trump and GOP leaders to pass the bill is the conservative House Freedom Caucus.

The group, headed by Rep. Mark Meadows of North Carolina, has been against the AHCA since its introduction because it does not deliver on their promise of fully repealing Obamacare. The GOP rolled out a large amendment on Monday with a series of changes to the bill in order to win over the Freedom Caucus, but it failed to move the needle.

According to the group, they have roughly 25 votes against the bill, enough to kill it.

In an attempt to placate the group, Trump has been negotiating directly with conservatives about possible last-minute changes that could make the bill more palatable.

According to reports, the White House is willing to drop Obamacare’s essential health benefits — the provision that forced insurers to cover certain types of ailments. While this comes with a myriad of issues, not the least of which is possible pushback from moderates, it still does not seem to be enough to win over the Freedom Caucus.

(Read more about the impact of dropping essential health benefits»)

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Rep. Mark Meadows Mark Wilson/Getty Images

According to Bill House, Anna Edney, and Jennifer Jacobs at Bloomberg, Meadows and the Freedom Caucus have asked that the provision of Obamacare that compels insurers to cover people with pre-existing conditions be dropped, which the Trump administration has flatly refused.

“Addressing pre-existing conditions has always been a requirement for any replacement plan that HFC would support,” Meadows told reporters.

The pre-existing conditions provision is the most popular part of the ACA, with nearly 80% support in many polls.

While it does not appear that a deal has been reached, the Freedom Caucus is expected to head to the White House for further negotiations on Thursday.

Moderate defections

The Freedom Caucus is not the only group within the Republican party coming out against the bill.

Some moderate Republicans have defected from the party line, saying that the AHCA does not meet their requirements for an Obamacare replacement plan.

Rep. Charlie Dent of Pennsylvania, a moderate GOP member, said Thursday morning that he will not vote for the bill.

“I believe this bill, in its current form, will lead to the loss of coverage and make insurance unaffordable for too many Americans, particularly for low-to-moderate income and older individuals,” said Dent. “We have an important opportunity to enact reforms that will result in real health care transformation — bringing down costs and improving health outcomes. This legislation misses the mark.”

Other moderate members like Reps. Frank LoBiondo and Chris Smith of New Jersey along with Rep. David Young of Iowa all came out against the AHCA on Wednesday.

LoBiondo, in fact, said that the bill did not even measure up to the current Obamacare system.

“It is not as good as or better than what we currently have,” said LoBiondo in a statement. “Accordingly, I will vote no on this health care plan.”

Outside pushback

At the same time that the furious negotiations are happening on Capitol Hill, outside political groups have also taken stances against the AHCA.

Conservative action groups including the Club for Growth, FreedomWorks, and Heritage Action have all come out against the bill, saying that it does not do enough to alleviate the issues of Obamacare. In addition, these groups have pegged the AHCA vote to what is called a key vote. This means that if a House members votes for the bill, their “score” (a measure of how much the group supports the particular lawmaker) will drop, and could in turn impact the support the House representative receives in the next election.

Additionally, policy groups have warned that the current version of the bill could have serious consequences for the healthcare system. Drew Altman, CEO of the nonpartisan health policy think tank Kaiser Family Foundation, wrote in Axios on Wednesday that the current bill would increase out-of-pocket costs as more people are shifted to high deductible plans.

Additionally, the Brookings Institution warned that recent amendments to bill could actually make the number of people losing health coverage due to the AHCA worse than the Congressional Budget Office’s original estimate of 24 million over the next 10 years.

Last procedural hurdle

Before the bill can advance to the full House for a vote there is still one procedural step it has to go through.

The House Rules Committee suspended its hearing on the AHCA Wednesday after debating the bill for roughly 12 hours. The committee will reconvene on Thursday before submitting the bill to the House floor.

The House Rules Committee determines a number of key frameworks for the debate and amendments that can be considered for the bill while it is on the floor.

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