The White House claimed talks between Donald Trump and House speaker Paul Ryan were ongoing on Friday as the Republican effort to repeal and replace the Affordable Care Act stood on the verge of potential defeat.
“They are continuing to discuss the way forward on this,” the White House press secretary, Sean Spicer, said after the most senior congressional Republican traveled to the White House to see the president. “The speaker is updating him on his efforts.”
Donald Trump had been calling House members from early in the morning to late at night to lobby for the legislation, Spicer added. “He’s left everything on the field when it comes to this bill ... The president and his team have committed everything they can to make this thing happen.”
Spicer insisted that there would still be a vote on the the American Health Care Act (AHCA) on Friday afternoon. “We are proceeding with a 3.30 vote as scheduled,” he said, although no vote has been formally scheduled.
He said: “The question is can we get to 216 [votes]? But make no mistake about it, the president made clear last night that this is it.”
A downbeat Spicer added: “At some point you can only do so much ... We are confident that we have done everything and it’s now up to the voters [in Congress ... And I think that now’s the time for the vote.”
Asked if the buck stopped with Trump, the press secretary replied: “You can’t force someone to vote a certain way. Has he done every single thing, has he pulled out every stop, has he called every member, has he tweaked every tweak, has he done every single thing he can possibly and used every minute of every day to get this thing through, then the answer is yes.
“Has the team put everything out there, have we left everything on the field? Absolutely. But at the end of the day this isn’t a dictatorship and we’ve got to expect members to ultimately vote how they will according to what they think.”
Trump, the author of The Art of the Deal, employed an unconventional negotiating strategy on Friday morning – mocking conservatives for being insufficiently anti-abortion.
“The irony is that the Freedom Caucus, which is very pro-life and against Planned Parenthood, allows P.P. to continue if they stop this plan!” Trump tweeted, referring to the hard-right group of conservative legislators.
The AHCA includes a provision to defund the women’s health organization, which has long been a bête noire for conservatives opposed to abortion rights who strongly object to taxpayer money going to an organization that performs abortions.
Prior to his run for president as a Republican, Trump described himself as “very pro-choice”. Even on the campaign trail, he went out of his way to praise Planned Parenthood, saying that the organization had done “very good work for millions of women”.
Freedom Caucus members, who held a late-night meeting Thursday on Capitol Hill to plot their strategy, are skeptical of the AHCA on the grounds that it leaves too much of the architecture of the Affordable Care Act, widely known as Obamacare, in place. However, they won one major victory on Thursday when they were able to add a provision removing the federal mandate for “essential health benefits” in the bill and letting states decide which health benefits were essential. Under the current law, all health insurance plans are required to cover these 10 services, including maternity care, mental health, prescription drugs and both inpatient and outpatient care.
This concession helped to win over hesitant conservatives, including some members of the Freedom Caucus.
But a number of conservatives remain dissatisfied, while at the other end of the spectrum, some Republican moderates believe the legislation goes too far and would result in too many people losing their health coverage. A report from the nonpartisan Congressional Budget Office estimated that 24 million fewer Americans would have health insurance in 2026 if the AHCA passes.
Twenty-two Republican defectors would be enough to lead to the AHCA failing in the House. No Democrats are expected to vote for the bill.
Republican Mark Amodei of Nevada, an opponent of the bill, saw this number as being relatively easy to reach. “You’re going to get some noes out of the Freedom Caucus, get some noes out of those 59 people elected in Hillary Clinton-voting districts, and then you have some of the people in the middle and we don’t fit into any label and I think you’re going to get some of those too,” said Amodei.
He noted “that doesn’t require a lot of noes from each [group]”, adding that 22 “doesn’t seem like a monster number”.
Among the Republicans opposing the bill is Rodney Frelinghuysen of New Jersey, who is the chair of the House appropriations committee. It is almost unprecedented in recent congressional history for such an important figure to oppose the House speaker on a major legislative priority.
The bill is politically risky: although recent polling from Quinnipiac University showed that a majority of Americans wanted at least some changes to Obama’s health law, it also pegged current support for the AHCA among voters at only 17%.
Democrats seemed eager to use the vote for political leverage in midterm elections. The House minority leader, Nancy Pelosi, predicted in a press conference on Friday: “The people who vote for this will have this vote tattooed to their foreheads as they go forward. They have to answer for the vote.”
But the blame game was also being played on the other side of the aisle.
Amodei complained to reporters that his caucus “didn’t spend a lot talking about a unified Republican vision for what we should do with healthcare in the House”, while Paul Gosar, a member of the Freedom Caucus, pointed a finger at White House staff.
“We need to get this across the finish line, but [Trump’s] relying a lot on his staff,” said Gosar. Further, sources close to the White House have been pushing the blame on Paul Ryan in discussons with reporters from several outlets.
Democrats took their own lessons. The House minority whip, Steny Hoyer, told reporters that Republicans “find themselves in this position because they have now for a very long period of time said to themselves that they don’t want to include Democrats”.
Obamacare, the former president’s signature domestic policy achievement, enabled 20 million previously uninsured people to obtain health coverage, about half from an expansion of Medicaid that the new bill would end. It established subsidized state marketplaces for health insurance, which have struggled with rising monthly fees, set out what coverage insurers must offer, and barred insurance companies from excluding the sick from coverage.
The Republican plan ends Obamacare’s taxes, eliminates the requirement that all Americans have insurance and dramatically cuts Medicaid, the healthcare program for low-income Americans. Instead of subsidies, the plan would offer tax credits to help people purchase health insurance.