Representative Charlie Dent of Pennsylvania is still opposed to the GOP legislation.J. Scott Applewhite / AP

Updated on April 25 at 3:02 p.m. ET

The fate of the resurrected American Health Care Act in the House might now rest with Republican moderates.

Forgive them for not celebrating their newfound clout.

Conservative leaders of the House Freedom Caucus have struck a deal with the White House and one leading GOP moderate to back the party’s stalled replacement for the Affordable Care Act in exchange for granting states even more flexibility to wriggle out of the law’s insurance mandates. Under the proposed amendment, states could seek waivers from the federal government, allowing them to eliminate the prohibition on insurers charging higher premiums to people with pre-existing conditions and a requirement that plans cover a range of “essential health benefits,” including maternity care, mental-health treatment, emergency room visits, and hospitalization.

The Freedom Caucus has been targeting those core mandates from the start, arguing that they force insurance companies to increase premiums on all customers to pay for the sickest people. And after weeks of talks, the group’s chairman, Representative Mark Meadows of North Carolina, agreed to a compromise authored by a co-chairman of the moderate Tuesday Group, Representative Tom MacArthur of New Jersey. The Freedom Caucus formally endorsed the new bill on Wednesday. Its backing could bring another 15-20 conservatives aboard and draw the GOP leadership much closer to the 216 votes it needs for passage in the House. Republicans can lose no more than 22 votes, and about a dozen moderates were publicly against the original legislation.

“We think the MacArthur amendment is a great way to lower premiums [and] give states more flexibility while protecting people with pre-existing conditions. Those are the three things we want to achieve,” Speaker Paul Ryan told reporters on Wednesday morning, after a private meeting of the House GOP. “I think it helps us get to consensus.”

Yet the speaker acknowledged they hadn’t quite reached that consensus, and without the support of enough moderates, the bill could still fall short. While MacArthur is the author of the compromise, he was already supporting the bill to begin with. A former insurance executive, he’s only beginning his second term in the House and is not seen as a driving force within the Republican conference. Another of the three co-chairmen of the Tuesday Group, Representative Charlie Dent of Pennsylvania, had come out against the GOP bill and quickly declared himself unmoved by MacArthur’s amendment. So did Representatives Dan Donovan of New York, Ileana Ros-Lehtinen of Florida, and Frank LoBiondo of New Jersey.

“It doesn’t address the concerns that I had,” Donovan told me in a phone interview on Wednesday. Representing Staten Island and a slice of southern Brooklyn, Donovan is the only House Republican from New York City, whose residents could be hit hard by provisions restricting the use of tax credits in the GOP bill. Opinions about the MacArthur amendment were mixed during a meeting of the Tuesday Group, he said. While some members liked the additional flexibility for states, “there’s others who may have balked or taken a step back” because of the changes to the pre-existing conditions guarantee, MacArthur said.

In fact, of the more than a dozen moderates who were opposed to the American Health Care Act a month ago, none have yet said the new compromise changes their mind.

And why should it? The new proposal retains the $800 billion in cuts to Medicaid that moderates are leery of supporting, and it is not likely to improve the projection of the Congressional Budget Office that 24 million fewer people would have health insurance a decade after the law’s enactment. And although Ryan pointed out that the bill would technically preserve the federal protection for people with pre-existing conditions, a firm GOP pledge, that guarantee would be worth next to nothing if states could easily seek a waiver exempting them from the mandate.

Politically, moderates have more to lose than members of the Freedom Caucus by supporting a bill that, one poll showed, fewer than one-in-five Americans supported. They are more likely to hail from more centrist and Democratic-leaning districts where support for Obamacare is stronger. In a rapid warning of the political blowback lawmakers could face, the Democratic Congressional Campaign Committee immediately launched digital ads attacking Republicans over a provision in the MacArthur amendment that would keep Obamacare’s consumer protections for members of Congress while allowing them to be scrapped for their constituents. Another liberal group, American Bridge, unveiled a new ad on Wednesday hitting Republicans for breaking President Trump’s promise to maintain the ban on discrimination based on pre-existing conditions.

These more pragmatic members of the House GOP now find themselves in a familiar squeeze. For years, they’ve watched the balance of power within their party in Congress drift to the right. When Republican leaders are short of votes, they often first negotiate with the more recalcitrant conservatives and then rely on the loyalty of the moderates to secure passage of the bill. On health care, conservatives have indeed moved far off their original position. The bill the Freedom Caucus, along with key outside groups like Heritage Action, FreedomWorks, and the Club for Growth, have just endorsed falls far short of a full repeal of the Affordable Care Act.

Yet there’s ample reason for moderates to remain suspicious of their colleagues. Even with the revisions under the MacArthur amendment, conservatives know the AHCA will not pass the Senate as it is currently written. But by backing the package and securing political cover from conservative activists, they can now shed the blame for its defeat, passing it off either to the Senate or the more politically vulnerable House moderates.  “There’s still more work to be done on this bill in the Senate and on further health care reforms,” said David McIntosh, president of the Club for Growth, “but any GOP moderates who stand in the way at this point are proving that they simply don’t want to keep their campaign promises to get rid of Obamacare.”

Moderates have been seeking power in the Republican conference for years. They have it now on health care, even if it feels less like real influence and more like just another piping hot potato.

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