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Why the conservative push to repeal Obamacare is stalling yet again

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

The Trumpcare revival is flailing just a few days after it got started.

Republican lawmakers left a big meeting on Tuesday night signaling that there had been no great breakthrough on the issues that derailed the American Health Care Act two weeks ago. Another meeting is expected today, though it’s not clear what there is left to do. No new legislative text has been made public.

The overarching question is whether this was a real play to get a bill passed, or whether the competing factions would merely use it as an opportunity to blame the others for the impasse. The White House, House leadership, and the far right and centrist wings of the Republican caucus have all faced criticism for the original bill’s failure.

What’s clear right now is that things aren’t going well — and a new round of finger-pointing is already underway.

Arch-conservatives are putting the heat on moderates

When Trumpcare first failed last month, it was due in part to the arch-conservative Freedom Caucus. That group of three dozen or so lawmakers was mostly against the bill because it didn’t fully repeal Obamacare. President Donald Trump criticized its leaders publicly after the bill’s failure, even making tacit threats to support primary challengers against them:

Despite that impasse, Republican lawmakers and the White House have pledged to keep working on the issue and rumors of a new plan began popping up. Freedom Caucus leaders trumpeted a renewed optimism early this week that they’d get something done.

And a key ally of that group claims that those lawmakers were coming around on a compromise, only to have talks stall now because of the moderate “Coverage Caucus” — Republicans who want a bill that won’t cause big coverage losses.

In a blistering call on Wednesday morning, Michael Needham, who leads Heritage Action for America — one of the most prominent outside groups that had been opposed to the AHCA — laid the blame for the latest stumbles at the feet of moderate House Republicans, who are part of a coalition known as the Tuesday Group.

According to Needham, the White House presented conservatives with a plan on Monday that they would have accepted. It would have allowed states to broadly waive Obamacare’s insurance reforms, such as the rule that prohibits health plans from charging sicker people more than healthy ones and minimum requirements for what health insurance must cover.

For the Freedom Caucus, this would have been a compromise: The infrastructure of Obamacare would stay in place, but states would have the chance to create an alternative — though under such an alternative, fewer people would likely be covered and sicker people could see higher costs. Nonetheless, that plan would have gotten upwards of 20 votes from the Freedom Caucus, Needham said, which would seem to get the bill close to the 216 votes it needs to clear the House. A Freedom Caucus aide confirmed the group saw that proposal as a positive step.

But moderates balked, according to Needham, and that has derailed the negotiations for now.

Those centrist Republicans have been skittish from the start because they are concerned about the AHCA’s consequences for their constituents. The Congressional Budget Office projected that 24 million more Americans would be uninsured by 2026 under the initial bill. Many of those lawmakers have promised to preserve Obamacare’s protections for people with preexisting conditions, which the waivers favored by the Freedom Caucus would either directly or effectively unravel in states that sought them.

“This happened because of the intransigence of the Tuesday Group, which refuses to get to yes,” Needham said. “I think the Tuesday Group clearly wants to keep Obamacare in place.”

Because of the moderate opposition, Needham said the proposal had since been narrowed, allowing waivers only from the minimum insurance requirements and Obamacare’s limits on how much more health plans can charge older customers. He described that proposal as a “non-starter” for conservatives. That would appear to leave the bill again well short of what it needs to pass.

All this drama is bringing the contentious relationship between House leadership and the Freedom Caucus and outside groups like Heritage back to the foreground.

Alongside the moderates, Needham sought to put the squeeze on House leaders like Speaker Ryan for the failures of the latest talks. “It is the job of Paul Ryan to get them to vote yes,” he said. “It’s the job for Paul Ryan to get that original proposal through.”

Aides close to leadership have emphasized, however, that this latest effort is a White House-driven affair.

So the debate is back at the same dividing lines that stunted Trumpcare the first time around: Conservatives want to roll back as much of Obamacare as they can, but moderates are concerned about the consequences of doing so.

The White House is leading this effort, but nobody is sure what happens now

One thing is abundantly clear: This time around, replacing Obamacare is the White House’s show.

Trump administration officials are the common denominator in every meeting — they have met with lawmakers from the arch-conservative Freedom Caucus as well as members of the Tuesday Group who had previously supported AHCA. Vice President Mike Pence, budget director Mick Mulvaney and Health Secretary Tom Price helped lead the two-hour discussion with both wings at the Capitol on Tuesday night.

But now that the talks have run aground, you have to wonder: What did they think was going to happen? Did they really believe they were on the precipice of a deal? Or was this a show for the public, to try to save face from the bill’s humiliating defeat a couple weeks ago?

The prevailing theory among lobbyists is the latter. The AHCA’s failure was a big loss for the Trump White House in its first legislative push. Though President Trump signaled he was ready to move on, that wasn’t palatable for a party that had pledged for seven years to repeal Obamacare.

It looks likely to drag on. Heritage’s Needham said on Wednesday morning that lawmakers should go home on their scheduled two-week Easter break and figure out what to do next.

Ryan seems to be operating under the same assumption:

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