(Bloomberg) – A last-minute White House bid to win the support of reluctant House conservatives for the GOP Obamacare replacement bill by discussing possible changes risks losing the support of party moderates.

White House press secretary Sean Spicer said Tuesday the administration is talking to lawmakers about possible changes to the GOP leadership measure, but House Speaker Paul Ryan so far is resisting any significant revisions, according to a Republican aide.

Ryan faces a narrow path for getting the controversial measure through the House, particularly after the Congressional Budget Office estimated the measure could add 24 million Americans to the ranks of the uninsured in a decade.

That leaves President Donald Trump with a decision to make about whether to wade into the policy debate or let GOP leaders try to sort it out on their own.

[Image credit: Bloomberg]
[Image credit: Bloomberg]

House Republican leaders had hoped to pass their repeal measure in the full House as early as next week and send it to the Senate, where it’s facing even stronger skepticism from Republicans. But it’s unclear whether they have enough votes to pass it, with several conservatives and moderates announcing they can’t back it in its current form.

Senate Amendments

Trump spoke with Ryan and other House leaders Tuesday afternoon by telephone.

The House is still open to “refinements and improvements” to the measure, Ryan said Wednesday on Fox Business, but the main components of the bill will stay intact, because they are part of what he calls a consensus plan that was presented to voters in 2016.

Senators who have been airing their concerns with the bill will have their chance to amend it once it leaves the House, Ryan said.

The Budget Committee is set to advance the measure Thursday. Efforts to change the bill could come either Thursday or next week as the Rules Committee sets the floor procedure for the measure.

Even with that tight time frame, Trump’s administration waded more deeply into the details, with some members of the administration telling different groups they’re still open to suggestions. Opponents of the bill upped their criticism after Monday’s dire analysis of the Republican plan by the CBO.

The CBO found the GOP measure would cut spending by more than $300 billion over the next decade but would end up resulting in 18 million fewer people holding health insurance by 2018, just as House members all face voters in midterm elections.

GOP Friction

Democrats seized upon the findings as evidence Republicans should drop their bill, and they even created internal GOP friction. A senior Republican aide said moderate members are spooked enough by the CBO report that any changes to make the bill repeal Obamacare without elements of a replacement would make it even harder to pass.

Democratic Senator Joe Manchin of West Virginia said Wednesday on MSNBC that he told Trump several weeks ago that it won’t be possible to repeal Obamacare with legislation requiring 50 votes and then replace it with a bill that needs 60 votes to advance. He said he told the president most people who have Obamacare don’t know how they got it, but if it’s taken away, “they’ll know who did it to them.”

Representative Ileana Ros-Lehtinen of Florida, a moderate Republican, announced she couldn’t vote for the bill as written because “too many of my constituents will lose insurance and there will be less funds to help the poor and elderly with their health care.” Representative Rob Wittman, a Virginia Republican, also said he decided to opposed the bill because of the CBO’s findings.

Some senators, including Lindsey Graham of South Carolina and Susan Collins of Maine, have called for slowing down.

Graham said Wednesday on MSNBC that he would tell Trump, “If you can’t get a better deal, and if you can’t protect that 62-year-old worker in Greenville” from having dramatic premium increases, “stop, take a time out, let it collapse” and then turn to Democrats for help in replacing the system.

At the same time, conservatives continued to withhold their backing unless they got changes to the measure.

Medicaid Changes

The most significant change they’re pushing for is to move up the phase-out date for Obamacare’s Medicaid expansion, according to conservatives inside and outside of Congress Tuesday.

The current bill maintains the expansion for participating states until 2020, at which point enrollment would be frozen. Some conservatives are pushing for it to last only until 2018.

Other possible modifications include restructuring a tax credit to help some people pay for insurance and addressing insurance industry mandates through deregulation in this bill, rather than relying simply on executive action by Health and Human Services Secretary Tom Price. Making it easier to buy health care across state lines, something Trump ran on during his campaign, also is a possibility.

More generally, some conservatives and outside groups have been complaining that Ryan and Republican leaders have overly constrained themselves by sticking to a process to fast-track the bill in the Senate known as reconciliation, which bars items that don’t have any budgetary effect.

Some have been demanding a simple Obamacare repeal bill, to be followed by a more sweeping replacement bill. Ryan and others have said they chose the current path as the most likely to succeed in the Senate.

‘Real Good Progress’

Leading House conservatives in recent days said they have been encouraged by their talks with the White House.

"I think we’re making real good progress with the White House and leadership and I’m optimistic that we’ll see some good results in less than a week," Representative Mark Meadows of North Carolina, chairman of the House Freedom Caucus, said Tuesday. He didn’t provide more specifics.

Representative Dave Brat of Virginia, another Freedom Caucus member, said Tuesday that if leaders agree to move up the Medicaid phaseout and add language to repeal insurance regulations -- something leaders say they will get to later -- more House conservatives would be squarely behind the bill.

“That would get a lot of us closer to yes,” said Brat, who argues fixing the insurance regulatory regime should be an initial step to an overhaul and that doing it later is like putting “the cart before the horse.”

Tax Credits

Representative Mark Walker of North Carolina, chairman of the 170-member Republican Study Committee, suggested last week he could move toward supporting tax credits to low-income earners -- something he’s opposed -- if there was a decision to end Medicaid expansion in 2018, instead of 2020.

He also said he’d want to see some work or education requirement incentives for those who get Medicaid benefits. But he has also expressed doubt future Congresses will have the will to actually carry out a discontinuance of the expansion.

A senior House Republican aide said Tuesday that if leaders yield to conservatives on Medicaid and draw down the rolls of expansion even faster, they wouldn’t gain any net votes because more moderates would turn against the measure.

Representative Charlie Dent of Pennsylvania, a co-chairman of a group of House moderates, also said more Republicans could defect if Ryan and Trump give in on Medicaid.

“It jeopardizes support from center-right if they move the Medicaid window from 2020 to 2018,” Dent said on Tuesday. “Big problem. Huge problem.”

And the pushback from Senate Republicans also has been loud, particularly after the CBO report. A group of moderate Republican senators -- Rob Portman of Ohio, Lisa Murkowski of Alaska, Cory Gardner of Colorado and Shelley Moore Capito of West Virginia -- sent a letter to Majority Leader Mitch McConnell saying the House draft plan doesn’t do enough to protect Medicaid.

Bloomberg News