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One chart showing Paul Ryan’s rock and hard place

The factions of opposition to the Republican health care bill.

When President Barack Obama was in office, it was easy to think congressional Republicans were a relatively homogenous group of lawmakers who all opposed Obamacare at all costs.

It was their uniting message on health care — a rallying cry around which they would win back power.

But now that Donald Trump is president, the House Republican caucus is learning it’s a lot easier to oppose something than to be for something. After years of unity on the need to repeal Obamacare, Republicans are splintering over the American Health Care Act, the bill that would repeal and replace it. The hard part of passing the bill isn’t the raw number of lawmakers who opposed it. It’s that they split into several different factions with different beliefs and goals.

The U-shaped splintering of House Republicans

In this chart below, we highlight the Republican members that have been critical of the bill, sorted by where they fall on an ideological scale. Pay attention to this “U” shape:

We borrowed the scale from the Conservative Review, which scores each member’s voting record. What you see above is a valley of lawmakers in the Republican mainstream who tend to support the bill — and then opposition from both the right and the left.

Move one way and you alienate the other.

Placing lawmakers on this scale helps us better organize the groups that have chipped away at Speaker Paul Ryan’s majority — and it shows why it’s been so difficult for Ryan to find strategic ways to appease certain factions to pass this bill.

The Freedom Caucus, pulling to the right

The Freedom Caucus is a group of Republicans who are among the most conservative members in the House. In 2015, they threatened to bring the federal government to a halt over defunding Planned Parenthood, and it eventually led to the resignation of House Speaker John Boehner.

You can see them in the chart below, representing virtually all of the dissent from the most conservative members of the party. (There are new members who are part of the Freedom Caucus, but they don’t have a voting record — so they aren’t on the ideological scale.)

The caucus, led by Rep. Mark Meadows (R-NC), generally believes the bill doesn’t roll back enough of Obamacare — that too much of the law stays intact.

But as Vox’s Dara Lind writes, the Freedom Caucus is in the midst of an identity crisis. Their members don’t seem to have a coherent message on what their overarching goals are, especially now that there isn’t a Democrat for them to oppose in the White House. So other than wanting a replacement that is structurally different than Obamacare, what do they ultimately want?

Well, the lowest common denominator is that they want government to be less involved in health care, spending less federal money to help people get insured and having fewer requirements for insurers. It matters less whether that money goes to people based on age or income.

The final bill, as of Thursday night, includes some concessions to this group. It eliminates the 10 “essential health benefits” required for plans people buy on the individual market and small group health plans. These essential health benefits include hospitalization, preventive care, and maternity coverage. The bill also halts the Medicaid expansion from Obamacare and will, starting in 2020, roll it back.

The problem is that the more the bill changes to appease Republicans on the right, the more it risks losing votes from the other group that opposes it.

The more moderate Republicans, who want the opposite

Almost as an exact counterbalance to the Freedom Caucus are the more moderate House Republicans. We’ve simplified this by denoting members of the Tuesday Group, which consists of about 50 members who tend to be left of the party’s mainstream.

These members can hardly be called liberals, but their middle-of-the-road politics have made them a dying breed. The increase of political polarization, as well as the Republican Party moving ideologically to the right, has left them vulnerable to more conservative challengers.

Most of these members appear to be part of what Vox’s Andrew Prokop dubbed the “Coverage Caucus” — lawmakers who oppose the bill because they don’t want 24 million people, including their constituents, to lose insurance by 2026, as estimated by the Congressional Budget Office. This includes Rep. Ileana Ros-Lehtinen (R-FL) and Rep. John Katko (R-NY).

But that means their goals are almost exactly opposed to those of the Freedom Caucus.

About half the people who got insurance under Obamacare did so through an expansion of Medicaid to cover many more low-income Americans. Many lawmakers in this group represent poorer areas that benefit greatly from this expansion and would be hurt by the Republican plan, which freezes the Medicaid expansion beginning in 2020. People already enrolled in Medicaid can stay on it, but most people don’t just get on Medicaid and stay on it forever — they cycle in and out of the program as their income rises and falls. So the freeze would eventually kick many people out of the program.

The law would also hurt low-income Americans in other ways. Tax credits to buy insurance on the private market would be mostly based on age, not income — which would hurt low-income seniors in particular. (Check out the AHCA calculator, which helps make sense of the impact of this change.) If Ryan appeased this group, he would alienate the Freedom Caucus.

This process revealed that some Republican members believe it’s more important to keep the benefits of Obamacare than to repeal the law, either in practice or in name, and replace it with something that covers fewer people.

The smaller factions: More Coverage Caucus, rural lawmakers, and process sticklers

Here’s the chart of everyone who is part of neither caucus, but has expressed opposition to the bill:

Ryan can lose 22 Republicans and still pass the bill. So he could conceivably get the votes he needs by winning over, say, the Freedom Caucus — and then going after some these other lawmakers. That’s exactly what the last-minute changes Thursday night appeared to be aimed at doing, successfully winning over some (but not all) Freedom Caucus members.

But going after the members in the middle won’t be easy either. A handful of them — including Rob Wittman (R-VA), Daniel Webster (R-Florida), and David Young (R-IA) — could be considered part of the coverage caucus.

Another handful — including Don Young (R-AK) and Brian Fitzpatrick (R-PA) — had similar concerns, largely saying they worried the bill would hurt their districts. One major sticking point for them is that the AHCA tax credit doesn’t adjust for geographic differences, unlike Obamacare, so it ends up hurting people in rural areas, where insurance can be significantly more expensive. (This interactive map from the Kaiser Family Foundation illustrates this point well.)

And then there are a few other lawmakers — including Walter Jones Jr. (R-NC) and Rick Crawford (R-AR) — who are dissenting because of the process, whether it’s because they think it’s being rushed, or because they think they don’t think it’ll get through reconciliation, which is how the Senate can pass the bill with a simple majority.

Now, perhaps there’s a way to piece together enough votes. Maybe President Trump’s threats to AHCA dissenters will make a difference. Maybe Ryan can do some back-room dealing to get others on board. Maybe they can remind their fellow Republicans how hard they worked to get to a position where they can take a big swipe at President Obama’s most wide-reaching domestic legacy.

But after health care, Ryan and Trump plan to tackle another complicated, contentious subject: tax reform. Once they do, they might find that these factions aren’t going away. On top of dissent from the left and dissent from the right, at least one group will have another grievance: Some Republicans will be upset because they didn’t get their way on health care.

Our up-to-date whip count is here. This story used the most up-to-date numbers we had, as of Thursday night.

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