The Republican plan to repeal and replace the Affordable Care Act (ACA) has survived a damning report from the Congressional Budget Office, bipartisan opposition, criticism from virtually every corner of the healthcare industry, and even dueling powerpoint presentations.
This week, it is likely to face its most consequential test yet – a vote on the floor of the House.
Even though several members of that chamber have openly decried the American Health Care Act (AHCA), Donald Trump and GOP leaders remained confident this week that it was on track to pass.
At a rally in Nashville, Trump vowed to “repeal and replace horrible and disastrous Obamacare”. “It’s gonna be great. It’s gonna be great,” the president said of the replacement plan. “And then we get on to tax reductions, which I like.”
In the frenetic push to keep their longstanding promise to repeal the ACA, Republicans and White House officials are moving aggressively to court conservative support.
But they must also reassure an increasingly worried public, after a Congressional Budget Office report estimated that 14 million Americans would lose health insurance in the first year under the plan, and 24 million would be uninsured by 2026.
A Fox News poll found that a majority of respondents (54%) opposed or strongly opposed the Republican healthcare plan compared with just 34% who said they favored or supported it. Asked why they opposed the bill, 67% said it was because the legislation would make “too many changes” to Obamacare.
House speaker Paul Ryan eventually conceded that changes would have to be made to the AHCA, while conservatives opposed to it maintained they had enough votes to block its passage if such changes were not substantial.
The Republican plan would eliminate the current requirement that Americans purchase healthcare or face a fine, but keep popular provisions including a requirement that insurers cover the sick and allow young people to stay on their parents’ insurance.
On Thursday, the House budget committee passed the bill in a 19-17 vote. Three conservative members of the Freedom Caucus opposed it. By Friday one of the three, Alabama representative Gary Palmer, said he had changed his mind.
Palmer was among a dozen members of the conservative Republican Study Committee (RSC) invited to the White House to discuss their concerns with the president. After the meeting, Trump bragged: “Every single person sitting in this room is now a yes.”
The ACA, known to many as Obamacare, was on its “last dying feet”, he said.
North Carolina’s Mark Walker, chair of the RSC, said Trump won support by agreeing to allow states to impose work requirements on Medicaid recipients and to “block grant” federal funding for the welfare program, as opposed to the “per capita cap” policy currently in the bill, which would give states a set amount of money per person.
Asked how he would respond to constituents and colleagues who call the Republican bill “Obamacare-lite”, he replied: “You’re looking at some of the top conservatives in the House. We stand united today to move this forward for the American people.”
Republican leaders are still trying to shore up support. The chair of the Freedom Caucus, North Carolina’s Mark Meadows, said he “definitely” had enough votes to derail a bill without substantial structural changes.
Meanwhile, Democrats are seeking to turn the issue to their political advantage after years of being attacked.
Trump has promised that any replacement plan would have “insurance for everybody”. The CBO report made clear the plan will not do that.
Democrats are hammering that point at press conferences and rallies across the country. This week, Connecticut senator Chris Murphy offered a powerpoint presentation in response to one given by Ryan after the plan was first unveiled.
Several fiscal hawks and conservative advocacy groups are opposed to the AHCA, arguing that it retains too much of the ACA and does not do enough to lower the cost of premiums.
On Wednesday, hundreds of conservatives braved freezing temperatures for a “day of action” on Capitol Hill. At the event, organized by the grassroots groups FreedomWorks and Tea Party Patriots, activists waved signs that read “repeal Obamacare” and “keep your promise” and cheered when Republican lawmakers took the stage to trash the replacement plan.
“Failure is not an option,” the Texas senator Ted Cruz said, to applause. “If Republicans take this opportunity and blow it, we will rightly be considered a laughing stock.”
The bill also faces criticism from moderate Republicans, especially those from states that chose to expand eligibility for Medicaid under the ACA, and from influential organizations representing doctors, hospitals, insurers and patients.
Oregon representative Greg Walden, chair of the House energy and commerce committee, which approved the bill on a party line vote, dismissed the opinions of such groups, which include the AARP, the American Hospital Association and the American Medical Association, as part of a “medical-industrial complex”.
The bill next goes to the House rules committee, which will consider changes. Ryan has said he hopes to bring the bill to the floor for a full House vote next week. Republicans will need 216 votes, if all Democrats oppose as expected.
Republicans do not have much room to tinker with the legislation. If conservatives win too many concessions, the plan is unlikely to pass the Senate, where Republicans have raised a number of objections already.
The president himself has acknowledged the difficulty of drafting a bill that will pass muster on all sides.
“You do something for one side and the other side doesn’t like it,” he said.