It’s been a very rough day for the Republican health care bill

It's been a very rough day for the American Health Care Act.

• The House vote on final passage, planned for Thursday night, has been canceled. Depending on whom you ask, it might happen Friday, or maybe not until Monday. Or, if no deal with holdout Republicans is reached, never.
• There is still no final text of the bill, as Speaker Paul Ryan tries to rework its contents to win over enough wavering Republicans.
• That means, of course, that there's no CBO score for any of those hypothetical changes either. There is, however, a hot new CBO score for the slightly altered version of the bill Ryan released on Monday. Compared with the original AHCA, it would cost more without covering more people, the agency estimates.
• A meeting this morning between President Trump and more than 30 House Freedom Caucus members did not result in any deal.
• The ranks of the "Coverage Caucus" — Republicans opposing the bill because they think it would negatively impact their constituents — continue to slowly grow in the House, with Reps. Mark Amodei (R-NV) and Jaime Herrera Beutler (R-WA) coming out against the bill.
• A new Quinnipiac poll finds that the GOP plan is incredibly unpopular, with only 17 percent of voters approving of it and 56 percent disapproving. I can't emphasize enough how remarkable those Quinnipiac numbers are for a top presidential priority. Large majorities of Democrats and independents loathe this thing, and even among Republicans there's only plurality approval.

And yet... House Freedom Caucus Chair Mark Meadows (R-NC) said Thursday afternoon that he and the Freedom Caucus want to "get this done" and that "the president will get a victory," per Liz Goodwin of Yahoo News. To me, that sounds like someone who wants to cut a deal eventually.

But even if there is some sort of Meadows/Ryan/Trump compromise, Republicans will have two more problems to surmount in the House.

First, there are questions about whether Meadows can deliver all or almost all of the Freedom Caucus. Given the harshly critical public positions so many of them have staked out — Rep. Tom Massie (R-KY), who previously called the bill "a stinking pile of garbage," tweeted yesterday that he was changing his vote from "no" to "hell no" — that could be a difficult task.

Second, the tricky problem for Ryan is that he has to please two holdout groups with essentially opposite demands: The Freedom Caucus wants to roll back more of Obamacare's changes, and the Coverage Caucus is worried about doing just that. Major policy concessions to win over one group could drive away votes from members sympathetic to the other.

There are also a whole lot of Republicans who have not taken a position on this thing at all. According to the New York Times's whip count, only 145 House Republicans were in the "yes" or even "lean yes" camp as of Thursday afternoon.

That means around 70 members who are leaning no or who really haven't wanted to stick their necks out on this would have to come around awfully quickly to pass it. This could still happen — but with every passing day, it looks more difficult. And that doesn't even begin to get into the enormous challenges this thing will face in the Senate.

Chart of the day

Sarah Frostenson/Vox

"[To win over holdout Freedom Caucus members], the Republican health care bill may aim to repeal essential health benefits altogether for individual market health plans. Essential health benefits are huge for people with drug use disorders. Before, it was fairly common for insurers to leave out addiction treatment in their plans. If someone with a drug use disorder wanted to get coverage, she would typically need to find a more expensive plan that did include addiction treatment — and perhaps she wouldn’t be able to find a plan, particularly an affordable one, at all." —German Lopez, Vox

Today’s health policy and politics links

With research help from Caitlin Davis

• “Where the Republican health care bill stands right now": This is Vox's roundup of the latest news, and we're going to keep updating it throughout the night.
• "The fight over 'essential health benefits,' explained": "'Without these requirements, you are looking at an individual market where the only policies available are extremely skimpy or expensive,' said Matthew Fiedler, a fellow at Brookings who served as chief economist of the Council of Economic Advisers, where he oversaw work on the Affordable Care Act. In the past, insurers had strong incentives to design plans in ways that were unattractive to people with predictable health needs or sick people. And getting rid of the essential health benefits, Fiedler said, 'would give them a powerful tool to avoid people that expect to need care.'" —Julia Belluz, Vox
• "Trump's Obamacare repeal concessions likely can't pass Senate": "Senate Republicans may simply oppose the effort to sweep aside requirements that health insurance plans cover items like mental health care and maternity care — not to mention a separate proposal being floated in the House to allow insurers to once again block people with pre-existing conditions from coverage and to no longer allow young adults to stay on their parents’ health care plans until age 26. Those Obamacare provisions are popular among Senate Republicans and likely to remain in any final bill. But parliamentary rules could be the bigger problem..." —Burgess Everett and Jennifer Haberkorn, Politico
• "Republicans should be disgusted with the House Freedom Caucus": "Without this vote, they absolutely will not be able to meet their campaign pledges to replace Obamacare. And they will make the Republican Congress and the new White House look hopelessly inept, destroy any political momentum from the election, explode comity within the House and Senate Republican caucuses, and badly hobble the entire conservative agenda in a flurry of mutual recriminations." —Quin Hillyer, Washington Examiner
• "Senator Apologizes After Joke About Losing His Mammograms in GOP Bill": "Sen. Pat Roberts (R-KS), when asked if he supports scrapping EHBs, deadpanned: 'I sure don't want my mammogram benefits taken away.' ... Roberts soon tweeted an apology. 'I deeply regret my comments on a very important topic,' Roberts tweeted. 'Mammograms are essential to women's health & I never intended to indicate otherwise.'" —Alice Ollstein, TPM

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