The Growing Gap Between the House and the White House on Health Care

President Trump desperately wants a deal on health care, and he wants the House to pass it next week before his first 100 days in the White House are out.

That much is clear from the reports of a tentative agreement between the leader of the conservative House Freedom Caucus, Representative Mark Meadows of North Carolina, and a co-chairman of the moderate Tuesday Group, Representative Tom MacArthur of New Jersey, to break a stalemate over the GOP’s American Health Care Act.

What’s also clear, however, is that the House Republican leadership—the lawmakers that both call and count the votes in Congress—shares neither the optimism nor the urgency of the White House. Speaker Paul Ryan said after a speech in London on Wednesday that Republicans were putting “the finishing touches” on a new proposal, after the party stumbled badly last month on its initial attempt to repeal and replace the Affordable Care Act. But on Thursday, a senior GOP congressional aide dampened expectations for the bill, which a senior White House official told The Washington Post could receive a House vote as soon as the middle of next week.

“The question is whether it can get 216 votes in the House and the answer isn’t clear at this time,” the aide wrote me in an email. “There is no legislative text and therefore no agreement to do a whip count on.”

These mixed signals are the latest example of the yawning expectations gap between Trump and Ryan over what Congress can achieve on the vexing question of health care. Reluctant to acknowledge defeat, the president has repeatedly insisted over the last several weeks that an agreement is close at hand, that the differences separating the hardliners in the Freedom Caucus from the more pragmatic and electorally vulnerable moderates are bridgeable. “It’s evolving,” the president said Thursday during a press conference, in which he denied there was ever “a give-up” on the issue. (His top aides had told House Republicans that Trump would move on from health care if they didn’t pass the bill last month.) “The plan gets better and better and better, and it’s gotten really, really good, and a lot of people are liking it a lot,” Trump said. “We have a good chance of getting it soon.”

But while Ryan has made a public show of confidence, his office has been much more skeptical about the prospects for reviving the AHCA, having seen first-hand how narrow the path is for writing a policy that can win the votes of conservatives without sacrificing the support of Republicans closer to the political center. Conservative activists also sense that the speaker is fearful of being burned again on a bill for which he expended significant political capital and lost.

The basic dynamics haven’t changed: Members of the Freedom Caucus want to repeal more of Obamacare’s insurance mandates than the AHCA initially scrapped. They argue that doing so is central to the GOP’s long-standing promise of a complete repeal and that the requirements that insurance companies cover certain essential health benefits and accept even the sickest customers are driving up premiums for millions of Americans. Moderates, however, are leery of breaking another pledge Republicans have made repeatedly—that they would not do away with Obamacare’s popular protections for people with preexisting conditions.

As reported by The Huffington Post and Politico, the agreement Meadows and MacArthur have struck would deal with the mandates by letting the states opt out of many of them, so long as they demonstrated that an alternative policy would seek to lower premium costs and expand insurance coverage. In theory, the compromise would let conservatives declare they have weakened Obamacare’s mandates and given states more power over health-care policy. And moderates hailing from Democratic states could assure their constituents that, in all likelihood, they would not lose the protections they currently have because their governors or legislatures would not opt out of the federal mandates.

But the proposal faces any number of pitfalls, both practically and politically.

The Conservative Quandary

Meadows, the third-term North Carolina conservative, genuinely wants to play the role of dealmaker. Despite the president’s occasional ribbing, he’s on good terms with Trump and would like nothing more than to win his praise by delivering a health-care deal that once seemed dead. But it remains an open question just how much sway Meadows has with his own members in the Freedom Caucus. He has claimed that he could have delivered some two dozen votes for an earlier proposal from Vice President Mike Pence, but the House GOP leadership has privately voiced doubts about his influence. It’s clear there are some members of the Freedom Caucus, such as Representative Justin Amash of Michigan, who are unlikely to support any bill that retains the structure of the AHCA. The GOP can lose no more than 22 votes, and a number of moderates are similarly opposed to the legislation because it goes too far to the right at it is.

Wrong Deal-Maker?

MacArthur may be a co-chairman of the Tuesday Group, but he was already supporting the House GOP bill, so his backing of a compromise doesn’t automatically alter the dynamic on the center aisle of the Republican conference. The leadership was well short of the 216 votes it needed in March, and party officials have warned that just about any deal they struck with the Freedom Caucus would result in a net loss of votes because it would scare moderates away. MacArthur’s endorsement could help prevent that kind of exodus, but it’s unlikely to flip many votes among the dozen or so moderates who were previously opposed.

Moderates have even more reason to be wary because conservatives are itching to lay the failure of Obamacare repeal at their feet after the Freedom Caucus drew the bulk of the blame last month. After Meadows endorsed Pence’s proposal in March, activist groups like Heritage Action and the Club for Growth attacked GOP centrists for blocking progress on the bill.

Political Suicide?

Republicans in the White House and on Capitol Hill were plainly embarrassed by their failure on health care the first time around, when they abandoned an ironclad promise without so much as a vote. The whiff had a much bigger ripple effect on their agenda, threatening Trump’s even higher priority of tax reform.

But to political analysts, the idea that the president and the House GOP would revive the AHCA is akin to escaping a burning building and then rushing back in for no good reason. The original bill had a ghastly 17 percent approval rating and had virtually no natural constituency other than Democratic activists eager to make Republicans pay for supporting it. The legislation has continued to dominate town-hall events during the current congressional recess, prompting lawmakers who had been on the fence, like Representative Jeff Denham of California, to declare their opposition after the fact.

Within hours of the reported agreement, statements denouncing the policy flooded in from progressive groups accusing Republicans of breaking their promise to people with preexisting conditions and trying to paper over their deceit. “The MacArthur amendment makes a bad bill even worse,” wrote the co-directors of Health Care for America Now, Margarida Jorge and Ethan Rome. “The only people this amendment will help are the members of Congress scrambling to pass any repeal bill for partisan political reasons, no matter how bad it is for their constituents. Millions will still lose their health insurance. States can still avoid critical consumer protections. Insurers can still refuse to provide basic coverage, institute annual and lifetime caps on the care they cover, and charge people with preexisting conditions more just because they need care, effectively pricing people out of the market.” Jessica Mackler, the president of American Bridge, called the idea of letting states opt out of Obamacare mandates “an insidious backdoor to hammer individuals with preexisting conditions and ending coverage for essential services like hospitalization, maternity care, and prescription drugs.”

The Specter of a Government Shutdown

As I wrote on Tuesday, Congress has a more urgent matter to consider when lawmakers return to Washington next week: They’ll have just a few days to avert a partial shutdown of the federal government. Funding expires on April 28, and the two parties have yet to announce a deal to appropriate money for the remaining five months of the fiscal year. At minimum, Congress must pass a stopgap measure to buy more time for negotiations if they want to keep the government open, and Republican leaders have said this will be their top priority in the days ahead. Asked on Thursday whether he wanted a vote on health care or on a funding deal next week, Trump replied: “I want to get both. Are you shocked?”

Remember the Senate?

Lest the president forget, the U.S. Congress is a bicameral legislature. Even if the House were to pass a major health-care bill in time for Trump’s 100-day marker, the legislation would still be a long way from becoming law. The proposal’s prospects were already precarious with the narrow Republican majority in the Senate, and the changes under consideration in the House could further imperil it in the upper chamber. Passage in the House would likely spur another several weeks of negotiations, if not months. Trump may be impatient to demonstrate progress on health care, but as he learned when he initially tried to shoehorn a House vote last month, wishing Congress would do something doesn’t make it so.