WASHINGTON — President Donald Trump delivered an ultimatum to House Republicans on Thursday night: Vote to approve the measure to overhaul the nation's health care system on the House floor today, or reject it and the president will move on to his other legislative priorities.
The president signaled that the time for negotiations was over with rank-and-file Republicans who were meeting late at night on Capitol Hill to try to find common ground on the embattled package crafted by House Speaker Paul Ryan, R-Wis.
The move was a high-risk gamble for the president and speaker, who have both invested significant political capital in passing legislation that would rewrite the 2010 Affordable Care Act. For Trump, who campaigned as a skilled dealmaker capable of forging a good deal on behalf of Americans, it could either vindicate or undercut one of his signature claims. If the measure fails, it would mean that Obamacare — something that congressional Republicans have railed against for seven years — would remain in place.
"Disastrous #Obamacare has led to higher costs & fewer options. It will only continue to get worse! We must #RepealANDReplace. #PassTheBill," Trump tweeted from his official White House account as the meeting was wrapping up Thursday night.
It was far from clear, however, that Ryan and Trump have the votes to muscle the package through the House after several members of the hardline House Freedom Caucus refused to back the package following a marathon session of negotiations Thursday with Trump and other top aides.
"We have been promising the American people that we are going to repeal and replace this broken law," Ryan said. "Tomorrow we're proceeding."
But the speaker refused to answer shouted questions from reporters after the meeting about whether he had the votes to pass the health care measure.
In a closed-door meeting with House Republicans on Friday night, according to Rep. Chris Collins, R-N.Y., Office of Management and Budget director Mick Mulvaney told his former colleagues "the president needs this, the president has said he wants a vote tomorrow up or down."
"If for any reason it's down, we're just going to move forward with additional parts of his agenda," Collins described Mulvaney as saying. "This is our moment in time."
Ryan had intended to bring up his plan for a vote on Thursday. But criticism mainly from conservatives caused that strategy to unravel after Freedom Caucus members rejected Trump's offer to strip a key set of mandates from the nation's current health care law.
"They're going to bring it up, pass or fail," said Rep. Mike Simpson, R-Idaho.
By evening leaders accepted the proposed change conservatives had rebuffed earlier, which would eliminate the law's "essential benefits" that insurers must offer under the ACA. Those include covering mental-health treatment, wellness visits, and maternity and newborn care.
They also added one sweetener for moderates, a six-year extension of a 0.9 percent additional Medicare tax on high-income Americans who earn above $200,000 if filing individually, or $250,00 if married and filing jointly. By keeping the tax in place, GOP leaders could provide another $15 billion to help some older Americans obtain health care coverage.
The negotiations over the legislation continued all day, even after leaders announced they would postpone a vote originally scheduled for Thursday. As evening came, members of the conservative House Freedom Caucus filed into the office of Ryan, as did White House Chief of Staff Reince Priebus and Trump's chief strategist, Stephen Bannon.
Meanwhile, a new analysis by the Congressional Budget Office released Thursday evening showed that changes House leaders made to the bill on Monday do not alter a projection that 24 million more Americans would be uninsured by 2026 under the bill. In addition, the updated bill would cut the deficit by $150 billion over the next decade — nearly $200 billion less than the earlier version of the legislation.
The changes include a couple of conservative overhauls to the Medicaid program and language directing that $85 billion be used to help Americans ages 50 to 64 obtain coverage.
It was unclear how the new CBO score would affect legislative support for the bill, although Rep. Brian Mast, R-Fla., who is undecided, said it is "one of the things I'm considering as we read the bill."
The new score was not the leadership's biggest problem. Speaking to reporters Thursday afternoon, the Freedom Caucus chairman, Mark Meadows, R-N.C., said House leaders were still seeking another 30 to 40 votes to pass the bill.
"I'm desperately trying to get to yes," Meadows said. "I think we need to make sure that it lowers health care costs."
House leaders confirmed that they still lacked sufficient support. And while conservatives posed the biggest challenge for House leaders, some key moderates are also against the bill.
White House press secretary Sean Spicer said during an appearance Thursday night on Fox News that the president remained confident the bill would pass.
"At the end of the day, this is the only train leaving the station that's going to repeal Obamacare," he said, adding that Trump always knew winning a majority would be tough.
"I think we're going to see the same level of success" as in last year's campaign, Spicer said. "He's left nothing in the field."
Trump devoted much of his day to personally lobbying members, meeting with conservatives Thursday morning and offering to remove the essential benefits package from the proposal. Lawmakers who support that proposal say it would reduce premium costs for Americans.
But Freedom Caucus members have asked to eliminate more — including language that bars companies from setting insurance rates based on a person's sex, medical condition, genetic condition or other factors. Their proposal would reverse the ban on lifetime or annual dollar limits on coverage, allow insurers to separate healthy and sick consumers into different risk pools, and undo the law's requirement that large insurers spend at least 85 percent of what they collect in premiums on claims, and refund the rest.
The only existing mandates Freedom Caucus members are open to preserving are ones that bar insurers from denying coverage based on pre-existing conditions and allow children to stay on their parents' plans until age 26.
At least 80 percent of the group voted Thursday afternoon to reject the latest offer from GOP leadership and the White House.
"The ball is in their court," said Freedom Caucus member Rep. Andy Harris, R-Md. "Our position has not changed."