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.