Conservatives in the House Freedom Caucus have shouldered the majority of the blame for the Republicans’ failure to repeal and replace the 2010 health care law, but GOP moderates may be equally — if not more — responsible for the impasse. 

There are arguably more hard “no” votes (members not likely to be convinced to move to “yes”) for the GOP leadership’s plan among moderate Republicans than there are among Freedom Caucus members.

The caucus, however, is the easier scapegoat. Many of its members vote against leadership’s plans more often than members from other factions of the GOP conference. But on this issue, the moderates have more to lose.

Several Republicans described health care as a deeply personal issue in their explanation for why it’s so difficult to find conference agreement over a single plan.

If you buy that rationale, it helps explain why moderates aren’t jumping on board with leadership’s bill like they have with measures to fund the government and to raise the debt ceiling. They can logically explain voting for compromise legislation that keeps the government open or the nation from defaulting on its debt.

But a similar rationale does not exist in the case of health care. Moderates are having trouble finding a logical reason to vote for a bill that would result in 24 million people not having health insurance.

Politically, repealing the 2010 health care law is a murky issue in many of the swing districts that moderate Republicans represent. If they vote for a repeal bill without a viable replacement to protect their constituents’ health care, they could face losing their 2018 re-election races.

Moderates who are supportive of the heath care bill understand the dilemma many of their colleagues face.

“They’re in states that are fairly liberal in their thought process to the role of government related to health insurance. They’re in states that expanded Medicaid. … They’re just very different parts of the country,” Rep. Chris Collins said last week.

Collins and his fellow New York Republicans are largely moderates from a state that expanded Medicaid, but most of their concerns were allayed with the addition of a provision to exempt most New York counties from contributions to the state’s Medicaid program. That addition, which Collins and Rep. John J. Faso helped secure, is one of the reasons Rep. Dan Donovan will likely never vote for the bill. The Collins-Faso provision does not apply to New York City, which Donovan represents.

Then there’s New York Rep. John Katko, who promised his constituents he would not vote for a bill that repeals the health care law unless there was an adequate replacement proposal offered at the same time. He explained in a statement that the GOP plan does not provide adequate market-based options for insurance access nor does it address skyrocketing costs.

Two “no” votes among New York’s nine GOP members is still a lot of division for a state that effectively secured a earmark to win its members support. In other delegations, the divide is even greater.

Four of five New Jersey Republicans announced they would vote “no” on the bill, positions which they appear to still hold. The state’s sole supporter of the bill is Rep. Tom MacArthur, co-chairman of the moderate Tuesday Group. MacArthur has become the de facto negotiator for moderates who are willing to support the bill, while the group’s longtime co-chairman Charlie Dent of Pennsylvania remains unlikely to flip to “yes.”

“I’ll listen, but I’m still a ‘no,’” he said last week.

Among a list of concerns, Dent worried that continuing to shift the policy to the right will make the legislation unpassable in the Senate.

“A lot of members here don’t want to walk the plank for a bill that may not ever be brought up, may not ever be passed by the Senate,” Dent said before the March 23 vote on the legislation was postponed and then canceled.

Vice President Mike Pence and Trump administration officials made the rounds last week among Republican caucuses, trying to whip up support for an idea they hoped would get conservatives on board without losing any moderate votes in the process. But the White House has not focused on what may happen to the bill in the Senate. Nor has it tried to win over many of the moderates who opposed the measure.

For example, those involved in negotiations frequently refer to MacArthur when speaking about talks with moderates, and sometimes the Tuesday Group’s co-chairwoman Elise Stefanik, but never Dent. Rep. Patrick McHenry, the House GOP chief deputy whip, complimented MacArthur and Stefanik last week for being “constructive.” Asked if his omission of Dent meant that he was not being constructive, the North Carolina Republican said only, “He’s a colleague and friend of mine.”

The negotiations with MacArthur and other moderates have focused on keeping the “yes” votes on board, rather than working through the hodgepodge of concerns raised by the moderate “no” votes.

In contrast, Pence targeted the bloc of “no” votes in the Freedom Caucus with a pitch to allow states to seek a waiver to opt out of certain insurance regulations. The proposed waivers gave the caucus hope that its concerns were finally being addressed, but then moderate “yes” votes started coming out against the idea.  

That see-saw effect of shifting negotiations between Republicans on the far right and those in the center has gone on for weeks. Most members remain optimistic they’ll find the right balance, but if they don’t, both sides will be to blame.

“There will be some people in both groups who can never get to ‘yes.’ And that’s OK,” MacArthur said. “We can lose 20-plus votes and still have this carry.”