After the American Health Care Act was pulled from consideration in the House, the Republican blame game began. The criticism was mostly about politics and not the policy itself (i.e., whether the bill was good or bad for Americans), but the jockeying over who gets the blame has taken on added importance now that President Trump and his administration are trying to revive efforts to reform the Affordable Care Act. If Trump doesn’t understand what went wrong with the AHCA, or does understand but can’t find a solution to last month’s failure, then he won’t be able to ensure that the new legislation gets the Republican votes it needs to pass the House now.
Trump and Vice President Mike Pence are struggling to get enough Republicans on board with the new effort. The reason is straightforward, but it’s almost impossible to solve: There was ideological opposition to the AHCA on both the left and the right wings of the Republican Party. After the AHCA went down, much of the focus centered on the very conservative Freedom Caucus, and Trump’s new bill seems to be designed to win that group over. But making the AHCA more conservative just pushes away moderates.
Sending the health care legislation down a more conservative path doesn’t make sense when it comes to getting votes in the House. The New York Times and The Washington Post between them identified about 50 House Republicans who were opposed to or had concerns about the AHCA just before it was due to be voted on in March. And a lot of those Republicans are moderates, as we can see on the chart below. House members on the left half of the chart are more moderate than the average House Republican, according to their DW-Nominate scores. (DW-Nominate scores are calculated using roll-call votes. There are two dimensions of DW-Nominate, but for the purposes of this discussion, we’re only focusing on the first dimension.1)
Of the 49 GOP representatives whose ideological scores we know (i.e., those who served in the House before this Congress) and who were probable “no” votes on the AHCA, a little more than half were more moderate than the average House Republican. Republicans can afford only 22 Republican defections, assuming all Democrats vote against the legislation. Therefore, even if Trump placated conservative House Republicans, there would still be enough opposition to sink the bill if no more moderate members came on board.
It also seems likely that additional moderate Republicans would come out against a more conservative bill. Most media whip counts looked only at those who said they were against or concerned about the bill in its previous form. The Times also put together a list of House members who said they were undecided or who never made a public statement. In the closing days of the original AHCA debate, many of those who came off the fence to say they were against the bill were moderate. Many of those who didn’t make their intentions clear were also moderate. Of the 30 who never said how they were going to vote and for whom we have ideological scores, 16 were more moderate than the average House Republican.
These moderates would also likely be pressured by their constituents to oppose a more conservative AHCA. Half of those 16 more-moderate members who didn’t reveal their opinions of the bill were from districts that the Democratic presidential candidate carried in 2012 or 2016. According to new polling data from the Kaiser Family Foundation, a health policy research organization, a majority of Democrats and independents think the AHCA didn’t pass because it went “too far in cutting existing programs.” That comes on top of a new poll from Gallup that found that a majority of Democrats and independents had a favorable view of Affordable Care Act.
When you consider the poll data and whip count data on the AHCA, it shouldn’t be surprising that some centrist Republicans are already pushing back against Trump’s renewed health care reform efforts. Still, Trump can’t afford to placate just the moderates while ignoring the Freedom Caucus: There are enough conservative Republicans to kill the bill too.
If Trump and congressional Republicans can’t come to an agreement on the AHCA, it’s hard to imagine that the party will be able to follow through on its much-promised “repeal and replace” plan for Obamacare in the near future. But there are other ways that Trump can reshape the health care landscape. The administration could use the Department of Health and Human Services to make numerous changes that could undermine the ACA or make it more conservative. In the Kaiser poll, a majority of people from across the political spectrum said that Trump should do what he can to make the ACA work. If Trump wants to follow the will of the people, that will mean setting aside efforts to repeal and replace Obamacare sooner rather than later.
Anna Maria Barry-Jester contributed reporting.