Republican leaders unveiled a new health care bill Thursday in their increasingly frantic effort to deliver on seven years of promises to repeal and replace "Obamacare." They immediately lost two key votes, leaving none to spare as the party's own divisions put its top campaign pledge in serious jeopardy.
President Donald Trump declared a day earlier that failure would make him "very angry" and that he would blame Senate Majority Leader Mitch McConnell, R-Ky.
But talking with reporters aboard Air Force One en route to France, Trump also acknowledged the challenges lawmakers face.
"I'd say the only thing more difficult than peace between Israel and the Palestinians is health care," Trump said. "But I think we're going to have something that's really good and that people are going to like."
The reworked bill McConnell presented to fellow Republicans aims to win conservatives' support by letting insurers sell low-cost, skimpier policies. At the same time, he seeks to placate hesitant moderates by adding billions to combat opioid abuse and help consumers with skyrocketing insurance costs.
But it was not clear whether the Republican leader has achieved the delicate balance he needs after a setback last month when he abruptly canceled a vote in the face of widespread opposition to a bill he crafted largely in secret.
Moderate Sen. Susan Collins of Maine told reporters she had informed McConnell she would be voting against beginning debate on the bill, citing in part cuts in the Medicaid health program for the poor and disabled. Sen. Rand Paul of Kentucky, who has repeatedly complained that McConnell's efforts don't amount to a full-blown repeal of Obamacare, also announced he was a "no."
That means McConnell cannot lose any other Republican senators. With Democrats unanimously opposed in a Senate split 52-48 in favor of the GOP, he needs 50 votes, with Vice President Mike Pence breaking the tie, to get past a procedural hurdle and begin debate on the bill.
The showdown vote is set for next week, though McConnell could cancel again if he's short of support. He and other GOP leaders are urging senators to at least vote in favor of opening debate, which would open the measure up to amendments. And GOP leaders express optimism that they are getting closer to a version that could pass the Senate.
"It's in the best shape it's been in so far," said Sen. Roy Blunt of Missouri. "Now that members actually have paper in their hand they can look at what is likely to be very close to the final bill we'll be voting on and move forward."
McConnell said the 172-page legislation is the senators' opportunity to make good on years of promises.
"This is our chance to bring about changes we've been talking about since Obamacare was forced on the American people," he said.
Many Republicans believe the party could face electoral catastrophe if it alienates GOP voters by failing to deliver after taking control of both chambers of Congress and the White House while vowing to get rid of former President Barack Obama's law.
"It could be the biggest political broken promise in many years," said conservative former Sen. Jim DeMint, former president of the Heritage Foundation, as he passed through the Capitol.
Throughout the day McConnell huddled in his office with holdouts, including Dean Heller of Nevada, the most endangered Senate Republican in next year's midterms, Shelley Moore Capito of West Virginia, Rob Portman of Ohio and John Hoeven of North Dakota.
The lawmakers wanted details and numbers on how the bill would impact rural and Medicaid-dependent people in their states. All had opposed McConnell's earlier bill, but this time around several exited their meetings saying they were undecided and needed more time to evaluate the legislation.
Hoeven said of McConnell: "He's asking everybody to work with him, and a lot of us are saying 'yeah,' and we've got more work to do."
Like legislation earlier passed by the House after struggles of its own, the Senate bill would get rid of Obamacare's mandates for individuals to buy insurance and for companies to offer it, repeal taxes and unwind the Medicaid expansion created by the Affordable Care Act. Analyses by the Congressional Budget Office have found the House bill and the earlier Senate version both would eliminate insurance coverage for more than 20 million people over the next decade.
The new bill contains language demanded by conservative Sen. Ted Cruz of Texas letting insurers sell plans with minimal coverage, as long as they also sell policies that meet strict coverage requirements set by Obama's 2010 statute. Moderate Republicans have objected that that would make policies excessively costly for people with serious illnesses because healthy people would flock to the cheaper coverage.
The Cruz provision appears in the legislative text in brackets, meaning specific language is still being composed. That could give McConnell, Cruz and other conservatives time to work out a provision with broader support.
The retooled measure retains McConnell's plan to phase out the extra money 31 states have used to expand Medicaid under Obama's statute, and to tightly limit the overall program's future growth. Since its creation in 1965, Medicaid has provided open-ended federal funds to help states pay the program's costs.
The rewritten package would add $70 billion to the $112 billion McConnell originally sought that states could use to help insurers curb the growth of premiums and consumers' other out-of-pocket costs.
It has an added $45 billion for states to combat the misuse of drugs like opioids. That's a boost over the $2 billion in the initial bill, an addition demanded by Republicans from states in the Midwest and Northeast that have been ravaged by the drugs.
To help pay for the added spending, the measure would retain three tax increases Obama's law slapped on higher- earning people.
And the legislation has a provision that appears to benefit only one state, Alaska, by setting aside some federal assistance for states with extremely high premiums. Alaska is the only state that fits the bill and it's home to a key senator McConnell wants to win over, Lisa Murkowski. It could gain nearly $2 billion over a decade, one analyst said.