Will Conservatives Kill Trumpcare?

The revolt against the American Health Care Act is being led by the party’s right wing.

Kentucky Sen. Rand Paul speaks about the ACA flanked by Utah Sen. Mike Lee and North Carolina Rep. Mark Meadows during a Tuesday news conference.

Mark Wilson/Getty Images

Vice President Mike Pence, former very conservative member of the House of Representatives, had a message on Tuesday to the current very conservative members of the House of Representatives and the Senate that are revolting against the newly released GOP health care plan: Get in line behind Trumpcare.

“As the legislative process goes forward, the president and I believe that the American Health Care Act is the framework for reform,” Pence said in the Capitol on Tuesday alongside the Senate Republican leadership. “We’re certainly open to improvements and to recommendations in the legislative process. But this is the bill, and the president supports the American Health Care Act.”

Conservatives have a different view of what the bill should be. To them, the American Health Care Act is “Obamacare Lite,” which repeals too little of the original and offers one too many new “entitlements.” Conservatives have the numbers to kill the bill—if they so choose. Will they?

The process of revealing GOP’s replacement for Obamacare after seven long years has gone for the House Republican leadership about as well as you might expect: like ripping a Band-Aid off, except immediately after ripping the Band-Aid off the searing pain just increases indefinitely. Republicans from Medicaid expansion states, like Ohio Sen. Rob Portman, have concerns about how the bill treats Medicaid expansion states. Relatively moderate Republicans, like Alaska Sen. Lisa Murkowski, do not think the bill should be touching Planned Parenthood. The bill defunds Planned Parenthood.

The most vocal resistance, though, has been from conservatives: The Freedom Caucus in the House and the conservative triumvirate of Sens. Rand Paul, Mike Lee, and Ted Cruz in the Senate. Each of these blocs is large enough to deprive their party a majority vote in their respective chambers, and the cavalry of outside conservative groups—Heritage Action, the Club for Growth, Americans for Prosperity (the Koch brothers), FreedomWorks—have backed them up with swift expressions of disgust at the bill.

Those minds that see the American Health Care Act as Obamacare Lite believe that the federal government should have little, if any, role in spending dollars to provide poor and lower-income people with access to medical care. If your baseline is that the Medicaid expansion should be undone and what remains of Medicaid should be slashed and block granted off to the states, that no federal dollars should be spent to help lower-middle income individuals obtain health coverage, that few federal regulations should govern the financing of and delivery of health services, and that no taxes should exist, then sure, this proposal would come across as “Obamacare Lite.”

The Freedom Caucus, along with Sens. Paul and Lee, held a press conference Tuesday afternoon outside the Capitol to explain that position. (Conspicuously absent was Cruz. It is worth keeping in mind that while the Texas senator has expressed similar misgivings with the bill, he is up for re-election in 2018 and cannot rule out a serious primary challenge from the establishment if he fails to mind his manners.) They portrayed “the bill” as “the leadership bill”—just one of several proposals floating around out there, any of which could be picked up. This view borders on denial.

“There are three plans out there,” Ohio Rep. Jim Jordan, the former chair of the Freedom Caucus, said at Tuesday’s press conference. “There’s the Cassidy–Collins plan, which is basically, ‘if you like Obamacare, you can keep Obamacare.’ There’s the leadership plan that was brought forward which I believe, when you look through it, is Obamacare in a different form.” The third plan is the Freedom Caucus–endorsed plan introduced by Paul and Rep. Mark Sanford. This plan would repeal just about everything and toss everyone some nonrefundable tax credits for health savings accounts in its place. It is not going anywhere in the United States Congress.

Conservatives agree that the best place to start is by re-passing the 2015 reconciliation bill that repealed most of the Affordable Care Act (but was vetoed by President Obama) and then move immediately to separate replacement legislation. Both Jordan and Paul said they would introduce bills in their respective chambers Tuesday for this “clean repeal.” They noted that Republicans were able to pass this two years ago, so it shouldn’t be a problem for them now. (The difference now is that Republicans no longer have President Obama’s veto pen to save them from the consequences of their purity.) Then, ideally, they would move immediately to passing their far-right plan.

But neither Paul’s replacement bill nor his “clean repeal” bill are going to be the vehicle for health care reform. Cassidy–Collins is not going to be the vehicle. The vehicle is going to be the American Health Care Act under its current framework or something relatively close. The only question now is whether these conservative groups in the House and Senate will commit to voting as blocs against a proposal that doesn’t fully repeal all aspects of the Medicaid expansion and offers refundable tax credits. It would be a gutsy move to go against the Trump-endorsed plan to “repeal and replace” Obamacare, and it may not work out so well for them. That’s why these conservatives aren’t yet being as categorical as to say they will definitely send this bill to its death barring fundamental changes.

“I think [what] the president and the vice president [are] saying is that the foundation there is a good foundation,” Freedom Caucus chair, Rep. Mark Meadows, said when asked about Pence’s comments. “We might disagree on that.”

If conservatives don’t get their way in these final negotiations, they will have a difficult decision to make.