President Donald Trump originally pinned the blame directly on the House Freedom Caucus as Republicans failed, first in March and again this month, to repeal and replace Obamacare.
You can’t point fingers at the archconservative Freedom Caucus for the impasse, though, now that they have collectively endorsed the bill. Another group is responsible for stalling the American Health Care Act: the moderate wing of the House GOP.
The problem for Trump and House leaders is those lawmakers’ positions aren’t as well-defined and appear fundamentally at odds with their conservative counterparts.
The Freedom Caucus has specific, pretty unified demands for Obamacare repeal. They want to gut the law’s insurance reforms — such as preventing insurers from charging sick people more than healthy ones and requiring a minimum level of benefits in health insurance — as much as they can.
Moderates, many of them part of a coalition called the Tuesday Group, are worried the Republican plan would cause too many people to lose health insurance. But beyond that, it’s harder to say what exactly they want. That makes it difficult to find a compromise as the White House and House leaders seek to avoid the embarrassment of failing to deliver on a central campaign promise.
Why the Tuesday Group isn’t like the Freedom Caucus
The Freedom Caucus tries to work as a unit, amplifying their visibility and their influence. The Tuesday Group, which got its name from its weekly lunches, isn’t nearly as well-known outside Washington, and doesn’t have the same cohesion.
“The challenge in negotiating with the ‘Tuesday Group’ is that it’s not and never was intended to operate as a bloc the same way the [Freedom Caucus] tries to operate,” one Republican health care lobbyist told me. “So it’s a bit like negotiating with Jell-O.”
The Freedom Caucus was born out of the Tea Party of 2009 and 2010, the logical extreme of small-government orthodoxy. They say they support “open, accountable and limited government” and they have been a thorn in House leadership’s side — they set events in motion that led to former House Speaker John Boehner stepping down in 2015.
They’re a tight-knit group and even have an informal rule that they will collectively endorse or oppose a bill only if 80 percent of their members agree to it. Their leaders, like Mark Meadows and Jim Jordan, are rock stars by Capitol Hill standards.
The Tuesday Group, perhaps by nature, doesn’t carry the same gravitas. Right now, they’re led by Reps. Charlie Dent of Pennsylvania, Tom MacArthur of New Jersey, and Elise Stefanik of New York. Other prominent members include former Energy and Commerce Chair Fred Upton and the No. 4 Republican in the House, Cathy McMorris Rodgers of Washington. Many of them come from mostly Democratic states, and they often represent suburban districts, where Republicans tend to be more moderate than in rural areas.
As the New Republic documented a few years ago, the group formed in the 1990s to prevent the House Republican conference from moving too far to the right. They worked primarily behind the scenes, scuttling bills related to abortion and helping secure spending for environmental causes, though they still failed to, say, prevent a government shutdown. Their public footprint has always been small.
And until the latest health care debate, they had usually been reliable votes for House leaders.
Conservatives are now attacking the Tuesday Group for wanting to keep Obamacare, trying to shift the blame for the AHCA’s failure, which has mostly been pinned on them.
The thing is, they aren’t totally wrong.
What does the Tuesday Group want?
Some lawmakers in the Tuesday Group support the AHCA, but enough of them don’t that the bill is still struggling to get the votes it needs to pass.
These lawmakers have voted to undo Obamacare before. In February 2015, almost all of them voted to fully repeal the law (only three of the 245 House Republicans voted against). That October, they did it again, on the bill that was a test run for the complex procedure Republicans are trying to use to pass the AHCA now.
But without the cover of President Obama’s veto pen, those same lawmakers have gotten skittish. The Congressional Budget Office’s estimate that 24 million more people would be uninsured is hanging over them, and they have suddenly found there is a lot of Obamacare that they like.
And as the White House and House leaders try to win their support, the underlying issue seems to be that Tuesday Group members don’t necessarily have a uniform, specific position on health care reform.
“The Tuesday Group is not anywhere near as ideological. These are more pragmatic conservatives,” Bob Laszewski, a health care consultant tracking the debate here in Washington, told me. “Since they’re not ideologues, they can’t sharply define what they believe.”
The deal breakers for moderates seem to fall into two camps, according to their own statements and lobbyists I asked: They want to keep Obamacare’s core insurance reforms, and they are worried about the $800 billion in Medicaid cuts, the result of capping the program’s spending and phasing out Obamacare’s Medicaid expansion.
Take Rep. Rodney Frelinghuysen of New Jersey. His opposition was stunning because he is close to leadership and chairs the influential Appropriations Committee. He captured both sentiments in explaining his position:
In addition to the loss of Medicaid coverage for so many people in my Medicaid-dependent state, the denial of essential health benefits in the individual market raise serious coverage and cost issues.
Another moderate “no” vote, Rep. Frank LoBiondo of New Jersey, said that “many South Jersey residents would be left with financial hardship or without the coverage they now receive” under the AHCA. He also cited the Medicaid cuts — remember that New Jersey is one of the states that expanded the program under Obamacare.
Others have very granular demands. Rep. Jaime Herrera Beutler of Washington, also a moderate from a blue state, won’t support the AHCA unless children are exempted from the bill’s Medicaid spending caps, her office told me.
And any tinkering with the bill to appease the Freedom Caucus risks losing more moderates. One Tuesday Grouper who had supported the bill, Rep. Tim Murphy of Pennsylvania, balked recently at the Freedom Caucus’s demand to roll back the Obamacare provision that prohibits insurers from charging sick people more than healthy people, known as community rating.
“I don’t think we will have something that eliminates community rating,” Murphy told the New York Times. “That just can’t be.”
Bottom line: parts of Obamacare are popular, and many Republicans want to keep them
With Obamacare more popular than it’s ever been and Trump deeply unpopular, it’s easy to see why some Republicans, particularly those who aren’t die-hard conservatives and who represent more evenly divided districts, aren’t eager to rip up the law root and branch.
The moderates may end up being the AHCA’s biggest hurdle to passage. Another health care lobbyist told me that their informal whip count, taken shortly before House leaders pulled the bill a couple of weeks ago, showed more moderates opposed to it than Freedom Caucus members.
That was proven true. The revised version of the legislation is still struggling to get the votes it needs, even after the Freedom Caucus’s endorsement.
These Republicans may never come out and say that Obamacare has created an insurance infrastructure that they want to keep. But if you parse their statements, that’s what’s happening here. That is the puzzle for them and Republican leaders to solve.
“It would be pretty hard for a Republican to stand up and say: ‘There are parts of Obamacare we need to keep.’ That would be politically incorrect,” Laszewski said. “But I think that’s what they really think.”