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Conservatives already concerned with the details of the GOP's effort to reform health care are now growing frustrated with Speaker Paul Ryan for the speed and manner with which the legislation is being moved through the House.
"At the end of the day, the people at home are seeing that this is run in a top-down fashion — that you have a few people who tell everyone else this is what we are going to do and that's it,” Rep. Justin Amash, R- Michigan told NBC News. “And, the place may have been more open under [former] Speaker Boehner, sadly." (Former Speaker John Boehner left Congress amid criticism from conservatives).
Republican complaints about the health care bill to repeal and replace the Affordable Care Act have grown since the measure was released Monday. The opposition that started over concern with some of the bills’ contents has intensified as Speaker Ryan has rejected calls to make changes to the measure.
After all-night hearings in two key committees, the bill cleared them both Thursday morning and heads to the House Budget Committee next. It will then go to a fourth committee - Rules - before it is brought before the full House for a vote, which could take place in two weeks.
President Donald Trump this week has hosted Republican members at the White House for meetings and social gatherings to try and build support for Ryan's efforts. In brief comments Friday before a meeting with GOP committee chairs, Trump emphasized a speedy timeline. "We must act now to save Americans from the imploding Obamacare disaster," he said, adding that 2017 is the year "it was meant to explode." Citing rising premiums, he said, "as bad as it is now, it will get even worse."
Despite the recent statements and charm offensive though, the president has done as much to hinder Ryan as help him. Trump has indicated to concerned lawmakers, both publicly via Twitter and in private meetings, that he’s open to negotiation on the details of the bill.
That's made Ryan's job of selling the current legislation to his members tougher and he's taken steps to remind them that parts of the plan have “actually been a cornerstone of Republican health care proposals all along.”
Ryan and his leadership allies point out that the drafting of health care legislation has been going on for the past year, and that leadership held many sessions for members to offer their ideas and hear from experts about health care during that time.
They point to over 200 hearings over the past seven years and “hundreds” of proposals offered. And Ryan notes the legislation is going through “regular order,” which means that the committees with jurisdiction are looking at the bill.
Conservatives say their requests to change the measure haven’t been accommodated by leadership.
“Do I expect all of the issues many of the Freedom Caucus would like would like to have to be in a final bill passage? The answer is no,” said Rep. Mark Meadows, R-N.C., head of the 40-member conservative Freedom Caucus. “It’s about a good-faith negotiation and I think all of our members are willing to do that.”
Some conservative concerns revolve around parts of the Affordable Care Act, or Obamacare, that won’t be repealed, including the essential benefits package, which is the minimum coverage an insurance plan can provide such as mammograms or maternity care.
Ryan says some of conservatives’ requests can’t be accommodated because of the confines of arcane Senate rules that allow Republicans to bypass the 60-vote threshold and pass instead with a simple majority.
“There are only so many things you can do in that bill because of the Senate floor rules for reconciliation,” Ryan said at a news conference that doubled as a health care power point presentation Thursday. “You can't put everything you want in that legislation because if you did, it would be filibustered and you couldn't even bring it up for a vote in the Senate.”
But some Republicans are starting to doubt the limitations under reconciliation, saying that it’s “an excuse” to avoid a more aggressive reform.
“Reconciliation is an excuse for not doing something they don’t want to do,” said David McIntosh, the president of Club for Growth, a conservative group that runs funds primary opponents against disappointing Republicans.
House Republican Leader Kevin McCarthy says that some of their concerns can be addressed through the administrative actions by the Health and Human Services Secretary Tom Price.
“Dr. Price knows what is possible, what is not possible and the various ramifications of change – we look forward to the President’s direct involvement,” he said. And leadership said they will bring up separate legislation that further rolls back Obamacare that can't be done in reconciliation the same week as the House votes on American Health Care Act.
McIntosh was one of many conservatives President Donald Trump has met with this week with conservatives at the White House on health care. In those meetings, Trump has indicated a willingness to negotiate on many of their concerns, including ending the Medicaid expansion earlier than the proposed 2020 and to reduce the requirements on insurance plans.
“I’m very confident based on my conversations with the White House the willingness to negotiate in good faith the things that drive down health care premiums,” Meadows said.
McIntosh and another person familiar with Trump’s meeting with conservative leaders said that what Trump indicated an unwillingness to negotiate was the age-based tax credits for people who purchase insurance in the individual market – something to which conservatives are opposed.
“That was an aggressive push back saying there is no plan without tax credits,” said a person familiar with the meeting, adding that Office of Management and Budget Director Mick Mulvaney added: “No serious person would criticize tax credits in that bill.”
But conservatives from multiple meetings have felt confident that Trump is more open to changes than Ryan and leadership. McIntosh added that Trump has been made aware of how their concerns with Ryan and his leadership.
“He knows from our meeting that they cut out the conservatives,” McIntosh said.