How Trump Tried to Close the Deal on Health Care

The president won over a group of conservatives by agreeing to push the Medicaid provisions in Paul Ryan’s bill further to the right. But key hardliners say the changes don’t go far enough.

Jonathan Ernst / Reuters

Republican leaders are desperate for President Trump to use his vaunted dealmaking skills to sell skeptical conservatives on their flagging American Health Care Act. They need his backing, and more importantly, they need the political cover he provides.

On Friday, the president delivered his first batch of votes.

After meeting with members of the conservative Republican Study Committee, Trump and House GOP leaders agreed to push the Medicaid provisions in their replacement for the Affordable Care Act further to the right. That was enough to win the support of the group, which represents the largest bloc of conservatives in the House. “We stand united today to move this forward for the American people,” proclaimed Representative Mark Walker of North Carolina, chairman of the RSC and an initial critic of the GOP health-care proposal.

According to a Republican aide briefed on the changes, states will now have the option of accepting a block grant from the federal government instead of receiving funding based on enrollment in the program under the leadership’s original proposal. They’ll also be allowed to institute work requirements for recipients, and states that did not expand Medicaid under Obamacare will be blocked from doing so during the transition. Under another revision, conservatives won the inclusion of language barring recipients from using the bill’s tax credits to pay for abortions. The changes are likely to be included in a manager’s amendment that would be unveiled next week before the final vote.

In the Oval Office, Trump boasted that he had secured the backing of all 13 lawmakers in the meeting. “I want everyone to know I’m 100 percent behind this,” the president said, giving Speaker Paul Ryan and his allies the full-throated endorsement they’ve been seeking for their bill. In a sign of confidence, the House leadership announced shortly after the meeting that they’d bring the revised bill to a full floor vote next Thursday.

Yet Trump remains far from closing the deal with conservatives. Only a few of the lawmakers comprising the baker’s dozen at the White House on Friday had vocally opposed the bill. Most were publicly undecided, and a couple were already onboard. The Republican Study Committee makes up well over half of the 237 members of the GOP House conference, and their support is necessary but not sufficient for the bill to gain the 216 votes it needs to pass.

Ryan and the president still need many of the nearly three dozen members of the hardline House Freedom Caucus to back the bill, as well as most of the moderate Republicans in the House. In a tweet, the Freedom Caucus said it remained opposed to the bill, and one of its members, Representative Justin Amash of Michigan, said it was “still a disaster.” None of the influential conservative activist groups opposed to the legislation—including Heritage Action, the Club for Growth, or FreedomWorks—had changed their position by early Friday afternoon. “Based on what I’m hearing, it’s not enough to get us on board with it,” said Jason Pye, public policy director for FreedomWorks.

GOP moderates had previously expressed concerns about the original Medicaid proposal in the bill, which would end its expansion under Obamacare by 2020 and cap its funding to states. Earlier on Friday, four Republican governors—John Kasich of Ohio, Asa Hutchison of Arkansas, Rick Snyder of Michigan, and Brian Sandoval of Nevada—cited the Medicaid language in formally opposing the legislation in a letter to Ryan and Senate Majority Leader Mitch McConnell. On the other side, Pye said FreedomWorks is pushing the House leadership to freeze enrollment in the Medicaid expansion and roll it back entirely earlier than 2020.

After Sandoval’s statement, Nevada Senator Dean Heller became the third Republican to officially announce his opposition to the current House bill. The GOP can afford no more than two defections in the Senate, and several other members have criticized the proposal.

House leaders, meanwhile, have already given up hope on the Senate quickly passing their bill without changes. “If they want to make additional changes, that’s called the legislative process, and we would encourage their ideas,” Representative Steve Scalise of Louisiana, the House GOP whip, said after the White House meeting. “We’re just happy to get this bill passed through the House.”

Trump helped with that effort on Friday, but if the reaction from the Freedom Caucus is any indication,  he’s still got a lot more negotiating to do.