The House of Representatives is expected to vote on the health bill as soon as Thursday — the seven-year anniversary of the Affordable Care Act's signing by Barack Obama.
Yet it's not clear that there are enough votes to pass the bill in the House and send it to the Senate, where it will face a fresh set of obstacles.
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"I never thought I'd have to say this, but we're facing an uphill battle in repealing Obamacare," Ryan said in a fundraising email Friday.
Ryan and his GOP lieutenants can afford to lose no more than 21 votes in the chamber, presuming all Democrats vote against the bill.
But they have yet to line up the backing of a block of about 40 conservatives members known as the House Freedom Caucus who argue that the current legislation doesn't go far enough in repealing Obamacare's programs that cover millions of Americans.
More than four-fifths of the Freedom Caucus opposes Ryan's bill, Alyssa Farah, a spokeswoman for the group, said Friday.
"We'll see; if it has the votes, it would be on the floor," said Representative Phil Roe of Tennessee, a member of Ryan's vote-counting team. "I know the core of the conference wants to get to yes."
Uninsured, hospitals
The current GOP bill, which could still be changed to try to gain support from conservatives, would cause 24 million Americans to lose their current insurance coverage by 2026, thanks to a shrinking of subsidies provided to help people buy coverage and a rollback of the Medicaid program for the poor.
Should it become law, it has the potential to pressure hospitals and health insurers as billions of dollars are taken out of the health-care system and the number of uninsured rises — leaving them unable to pay medical bills.
There are other signs of trouble for the bill, in particular among moderates in the Senate and in states, who oppose some of the changes being proposed to get the bill through the House.
On Thursday, four Republican governors, including Nevada's Brian Sandoval, wrote Ryan and Senate Republican Leader Mitch McConnell of Kentucky, saying they could not support the current proposal. "As we embark on this complex effort, we must ensure that individuals are not left without access to care," the governors wrote.
Following their message, Nevada Senator Dean Heller, a Republican, announced Friday he would oppose the bill.
"I agree with Governor Sandoval," Heller said in a statement. "I do not support the House bill in its current form." Republicans hold a narrow margin in the Senate and can afford to lose only two votes — and Heller joins other Republicans there who have expressed serious concerns, including Ohio Senator Rob Portman, Arkansas Senator Tom Cotton, and Maine's Susan Collins.
Trump's efforts
Trump has tried to bring holdouts on board, and while it's not clear how successful he's been he has adopted a posture of public confidence.
"It's all coming together beautifully," he said during a joint press conference Friday with German chancellor Angela Merkel. "It's going to be passed I believe."
He also said that "Obamacare will fail" on its own without action. "It will fold, it will close up very, very soon if something isn't done."
Trump met Friday with another conservative GOP subgroup, the Republican Study Committee, which includes about 170 House members. After the session, lawmakers who were there said the current bill would be changed to give states options to further limit Medicaid enrollment, a move that will help secure their backing.
"These changes definitely strengthen our number," House Majority Whip Steve Scalise told reporters on Friday.
Splits in caucus
Yet others say the changes still don't go far enough — many Republicans have called for total repeal of the law, with nothing to replace it.
"I remain firmly committed to repealing Obamacare," one of the RSC's founding members, Representative Jim Jordan of Ohio, tweeted on Friday. "I do not believe the AHCA currently does that."
"There is not saber-rattling. The noes on this bill desperately want to be yes out of a desire to support the president," said one House conservative who spoke on condition of anonymity. "But should the leadership force a vote on this current version, it will be defeated."
Representative Charlie Dent of Pennsylvania, a leader of a group of moderate House Republicans, said lawmakers should slow down. "If I hear one more senator tell me this is dead on arrival I think my head is going to explode," he said, before Heller's remarks.
Governors' letter
The governors, in their letter to Ryan and McConnell, said the legislation the House is considering would harm states and falls short of Trump's own goals of making sure individuals stay covered. The governors also backed continuing Obamacare's expansion of the Medicaid health program for low-income people, despite conservative insistences about rolling back the program.
The governors' proposal would keep an expansion of the program and make it available to other states that didn't expand it under the Affordable Care Act. The current House Republican bill would wind down the current Medicaid expansion starting in 2020, and there are proposals to start a wind-down sooner. The letter was sent by Nevada's Sandoval, as well as Ohio's John Kasich, Michigan's Rick Snyder and Arkansas's Asa Hutchinson.
The governors say in their letter that they oppose the Affordable Care Act, calling it "unsustainable." Shoring up the law's individual markets should take precedence over changes to Medicaid, they said, so that some individuals currently covered by that program could be shifted to private coverage.
"Access to affordable coverage outside of Medicaid for low-income individuals is critical to the effort to reduce reliance on Medicaid," the governors wrote.
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