GOP healthcare bill hangs in the balance

House Republicans are taking fire from all sides as they seek to push through their plan to repeal and replace ObamaCare, known as the American Health Care Act (AHCA).

Speaker Paul RyanPaul RyanWant bipartisan health reform? Make the debate honest again Ex-CBO directors defend against GOP attacks on ObamaCare analysis Ryan: CBO's healthcare estimate is 'bogus' MORE (R-Wis.) has guaranteed the bill will pass Congress, but it won’t be a smooth ride to President Trump’s desk.

Here are the factors that are likely to determine whether the legislation lives or dies.

The math

The Congressional Budget Office (CBO) is expected this week to release its score of the GOP legislation. 

Opponents of the bill on the left are eagerly awaiting the CBO’s analysis, which will estimate how much the plan will cost and how many people might lose healthcare coverage if it were enacted. 

The CBO is widely expected, even among Republicans, to estimate that millions of people would no longer have health insurance under the plan.

With that in mind, Republicans are already looking to discredit the office and downplay the importance of the score. 

“If you’re looking at the CBO for accuracy, you’re looking in the wrong place,” White House press secretary Sean Spicer said earlier this week. 

Ryan, meanwhile, compared CBO scores to a “beauty contest.” 

“Our goal is not to show a pretty piece of paper that says we’re mandating great things for Americans. Our goal is to get a vibrant healthcare system that’s patient-centered, that brings down costs, that increases choices, that has a marketplace so that we lower the costs and increase, and therefore increase the access to affordable care,” he said.

The Brookings Institution last week estimated that the CBO would report at least 15 million people would lose coverage under the measure.

While such a score is sure to make headlines, it remains to be seen how the report will affect the legislative debate — if it does at all.

The governors 

Republican governors from states that took ObamaCare’s Medicaid expansion are wary of the healthcare legislation. 

Thirty-one states expanded their Medicaid programs under ObamaCare, but the AHCA would phase it out starting Jan. 1, 2020.

“Phasing out Medicaid coverage without a viable alternative is counterproductive and unnecessarily puts at risk our ability to treat the drug addicted, mentally ill, and working poor who now have access to a stable source of care,” Ohio Gov. John Kasich (R) said in a statement Wednesday.

The governors met with the White House and GOP leadership about ObamaCare and Medicaid during their annual conference earlier this month, but Nevada Gov. Brian Sandoval (R) said this week the resulting plan “doesn’t include anything that the governors have talked about.”

“We’ve said all along ‘work with the governors,’ that it should be a governor-led effort and for the Congress to rely on their governors,” Sandoval said. 

Lawmakers pay close attention to pressure from their home states, so the objections of the governors could make a difference.

The outside groups 

Leading conservative groups have come out firmly against the healthcare proposal, saying it doesn’t live up to the GOP’s promise of fully repealing ObamaCare.

Heritage Action, FreedomWorks and Americans for Prosperity are all planning on upping the pressure on GOP leadership to make significant changes.

“This is simply not a full repeal of ObamaCare. It falls far short of the promises Republicans made to the American people in four consecutive federal elections,” AFP president Tim Phillips told The Hill Tuesday. 

“The proposed legislation trades one form of government subsidy for another government subsidy, and doesn’t roll back the mandate of ObamaCare. It’s a poor first attempt."

The groups provide financial and political support to back Republicans in their election races, and they could make life difficult for lawmakers in 2018 if they don’t fully repeal the healthcare law.

AFP is planning a campaign aimed at pressuring Republicans into a full repeal and told The New York Times it was prepared to bring “significant resources” to the fight.

Meanwhile, professional associations representing physicians, hospitals, insurers and seniors have all opposed the AHCA. Support from those groups was crucial to the passage of ObamaCare in 2010.

The town hall pressure

GOP lawmakers have faced pressure from constituents at town halls in recent weeks, with many calling on Congress to keep ObamaCare.  

The backlash is even happening in deep red states like Iowa and Kentucky. 

That pressure may cause some lawmakers to reconsider how they will vote on repeal legislation, but it also may not.  

House Ways and Means Committee Chairman Kevin BradyKevin BradyHealthcare debacle raises pressure for GOP on taxes Trump administration outlines negotiating priorities for NAFTA Charities push GOP for tax reform change MORE (R-Texas) said town halls would not alter Republican plans to repeal and replace the law.  

"I don't think it will," Brady said.  

"I think it's healthy to have these discussions."

The conservatives

The lack of conservative support is endangering the plan’s chance of passing the House.

Assuming all members vote and all Democrats vote no, it would take 21 House GOP defections to kill the bill. 

But members of the conservative House Freedom Caucus have blasted the legislation as “ObamaCare 2.0” and “ObamaCare lite,” mainly because of its reliance on refundable tax credits, which they call a new entitlement program.

Freedom Caucus members came out of their meeting Tuesday asserting that the bill does not have the votes to pass.

“Right now, the Speaker of the House does not have the votes to pass this bill unless he’s got substantial Democratic support,” said Rep. Mo BrooksMo BrooksConservative Senate candidate calls on GOP to end filibuster Strange faces tough Senate primary fight Freedom Caucus leader warns McConnell over Senate ad MORE (R-Ala.) 

Conservatives insist that Trump told them he is open to negotiating the contents of the bill, although House leadership has said they want to pass the measure as is.

“The conversations I’m having with members of the administration would indicate that they are still willing to negotiate in good faith. That has been reaffirmed time after time,” Rep. Mark Meadows (R-N.C.), chairman of the Freedom Caucus, said Friday.

Meadows also said it would be a “faulty assumption” if leadership thinks conservatives will eventually back the bill as drafted.

The president

Trump campaigned on the promise to repeal ObamaCare; now it’s crunch time.

“We must act now to save Americans from the imploding ObamaCare disaster,” Trump said while meeting with House committee chairmen at the White House Friday.

His backing of the AHCA could give it the momentum it needs to pass Congress. He’s been courting conservatives to support the legislation, most recently by bowling with members of the Freedom Caucus at the White House Thursday.

If GOP leaders are going to get the healthcare bill passed, they’ll need Trump to grab the bully pulpit and not let up. 

The Senate

The AHCA hasn’t even reached the House floor, but it’s already receiving pushback from Republican senators.

Sen. Tom CottonTom CottonCruz offers bill to weaken labor board's power Overnight Finance: GOP offers measure to repeal arbitration rule | Feds fine Exxon M for Russian sanctions violations | Senate panel sticks with 2017 funding levels for budget | Trump tax nominee advances | Trump unveils first reg agenda Iran deal faces uncertain future under Trump MORE (R-Ark.) said the House GOP should “start over” on its replacement plan.

“House health-care bill can’t pass Senate without major changes,” Cotton tweeted Thursday.

“To my friends in House: pause, start over. Get it right, don’t get it fast.”

The legislation has been criticized by at least 11 senators, including some from Medicaid expansion states who don’t want to see the expansion rolled back. 

Conservatives like Sen. Rand PaulRand PaulThe Hill's 12:30 Report Senate heads to new healthcare vote with no clear plan Overnight Healthcare: CBO predicts 22M would lose coverage under Senate ObamaCare replacement MORE (R-Ky.), meanwhile, are backing the Freedom Caucus’s push for repealing more of ObamaCare. Paul has introduced his own legislation to repeal ObamaCare.

Just three Republican no votes would likely sink the healthcare legislation in the Senate.