Office of Management and Budget director Mick Mulvaney made clear Thursday evening that President Donald Trump is done negotiating on the hotly-debated health care bill and wants a vote on Friday. House Republicans leaders abruptly canceled a vote on the GOP health care bill planned for Thursday evening as they struggled to find sufficient support to pass it.
The bill has been hamstrung by holdouts in the House Freedom Caucus, a hardline conservative group whose chairman, Rep. Mark Meadows R.-N.C., told reporters that there was still no deal after meeting with President Donald Trump at the White House Thursday afternoon. Negotiations, the Caucus said, are still ongoing.
Twenty-two House Republicans could vote against the bill, called the American Health Care Act, for it to pass. All Democrats are expected to vote against the measure.
House Republicans Who've Said They're Against the Bill
Below, see NBC News's updating list of House Republicans against or leaning against the bill.
The largest coalition against the bill is the House Freedom Caucus, 40-member conservative group. These more far-right members of the GOP wanted a full repeal of Obamacare, which the AHCA does not quite offer. However, Senate rules limit how much the House can repeal from existing law while still using a process requiring only a simple majority vote, complicating Republican leaders' ability to make a deal with Freedom Caucus members.
Other House Republicans voting no hail from areas where Obamacare expanded Medicaid coverage, providing more of its members with insurance. Medicaid has been at the center of efforts to transform the bill into something that will pass. Representatives also hail from areas with shrinking insurance markets, where premiums are on the rise.
Even before the vote cancellation, tweaks had been made to entice members, such as moving the timeline to undo the taxes imposed by Obamacare, adding a higher subsidy for seniors, and giving flexibility in block granting Medicaid. A deal was also made to please rural New York state by exempting contributions to the state's Medicaid fund.
A Look at the House Freedom Caucus
As Leigh Ann Caldwell reported in January, the House Freedom Caucus's ideological stance always jeopardized the passing of an Obamacare replacement. The Caucus wants a bill that does more to repeal Obamacare than the House's plan, and they're the core group holding Trump's bill hostage.
The Caucus demanded specific changes, such as rolling back Obamacare's "essential health benefits" insurance requirement — health care categories every plan is required to cover — and gutting popular components of the ACA that allows children to stay on their parents' health insurance until age 26 and requires insurers to cover preexisting conditions.
NBC News reports that the Trump administration offered a change that would leave the decision on "essential health benefits" to the states, but did not offer to any changes to the preexisting conditions requirement and the component allowing kids to stay on their parents' insurance.
After a meeting Trump at the White House Thursday, no deal was struck and the vote was subsequently delayed. The Freedom Caucus said they are still open to negotiating.
Representatives In States With Medicaid Expansion
Several representatives opposing the AHCA are from states with Medicaid expansions and have cited changes to Medicaid or effects felt by the poor as the reason for their opposition. These states would be hit particularly hard by the House Bill. "Our seniors on Medicare already struggle to make each dollar stretch," Representative Frank LoBiondo of New Jersey, who opposes the bill, said in a statement.
But at least thus far, Medicaid does not overwhelmingly explain the against and leaning against votes. Opposing members of the Freedom Caucus come almost equally from Medicaid expansion states and non-expansion states. Leading up to the vote on the bill, it was generally a fifty-fifty coin flip if a representative's home state expanded Medicaid and was also listed in NBC News's against or leaning against tally.
An analysis by the New York Times did find that vocal support of the bill is slightly lower among representatives in expansion states.
Representatives From States With Shrinking Insurance Markets
Many members hail from western North Carolina, central Tennessee, eastern Texas and western Arizona, areas where insurance markets are collapsing and Obamacare premiums are expected to rise. Many residents in these districts will need to change insurance providers.
A specific list of members from districts with troubled markets has not been made because some members are from counties adjacent to areas where many insurers are leaving. Health policy experts say effects on premiums can cross borders in these cases.
The below maps show the maximum change in the number of insurers in a district market between 2016 and 2017, according to the Kaiser Family Foundation.
These markets have also been through contentious political fights and turmoil in recent years. Some insurers, like Aetna, have made very public quits from the Obamacare insurance markets for politically-motivated reasons. Now, premium increases are expected in markets with less competition between insurers.
