The White House and Senate Republican leaders are planning a final, urgent blitz to pressure reluctant GOP senators to pass an overhaul of the Affordable Care Act before their month-long August recess.
Aware that the next 14 days probably represent their last chance to salvage their flagging endeavor, President Donald Trump, Vice President Mike Pence and Senate Majority Leader Mitch McConnell, R-Ky., intend to single out individual senators and escalate a broad defense of the evolving proposal, according to Republicans familiar with their plans.
When Trump returns from Europe, he plans to counter the nonpartisan Congressional Budget Office's analysis of the legislation - which shows that 22 million fewer people would have insurance coverage by 2026 than under the current law - with figures and analyses from conservative groups and Republicans that show more benefits and less disruption, should the bill pass, according to a White House official familiar with the strategy.
Pence, meanwhile, is being asked to help bring along skeptical GOP senators, including Sen. Dean Heller (Nev.), to whom he has already reached out personally.
McConnell is expected to place greater responsibility on Sen. Ted Cruz, R-Texas, to pitch his controversial amendment that would allow insurers to offer plans that don't meet ACA requirements - provided they also offer some that do. McConnell could ask Cruz to speak to Republican senators as soon as Tuesday, according to a person familiar with his strategy. Cruz has often talked about his amendment in the senators' regular Tuesday lunches, but the burden of building support for the bill could be left to the firebrand conservative.
The plans, which the Republicans described on the condition of anonymity, reflect the immense pressure GOP leaders feel as they aim to bring their bill to a vote on the Senate floor the week after next.
It is far from clear that the strategy will work. Even as Trump has sought to complement McConnell's efforts with his own, he has also complicated the majority leader's life - most notably urging a vote on strictly repealing the law if the current effort is unsuccessful. McConnell has floated a different backup plan: working with Democrats to stabilize the insurance markets.
The biggest challenge the leaders face is the widespread disagreement among Republican senators about how the nation's health-care laws should be structured, as well as frustration about the secretive process McConnell used to craft his bill. It was that anger and discord that spoiled McConnell's plan to vote on the bill before the Fourth of July recess and forced him to rewrite his draft.
"It may be that there is another discussion draft. If there is, I can't tell you what's in it. That's what happens when you don't have an open process," Sen. Lisa Murkowski, R-Alaska, said Friday at an event with constituents in Homer, Alaska.
Murkowski is one of several key moderate senators whom McConnell desperately needs to win over with his next draft, the details of which could be released as soon as early next week. He can afford to lose only two of the 52 Republican senators if he hopes to pass the bill. No Democrats plan to vote for the measure, but Pence is ready to cast a tiebreaking vote if needed.
McConnell must also woo recalcitrant conservatives who came out against the initial draft the day it was released. They include Cruz, who has been pushing his amendment as a means of winning his own vote as well as those of his conservative allies.
"It adds additional choices so that people who can't afford insurance now will be able to purchase some form of insurance that they want, that they desire, that helps meet their needs," Cruz said Thursday at a town hall in Austin hosted by Concerned Veterans for America, a group backed by the billionaire conservative Koch brothers.
But Cruz's amendment has drawn concern from critics who worry that it would destabilize the risk pool that brings together healthy and sick individuals, and that it could mean higher coverage costs for less-healthy people.
"There's a real feeling that that's subterfuge to get around preexisting conditions," said Sen. Charles Grassley, R-Iowa, according to Iowa Public Radio. "If it is subterfuge and it has the effect of annihilating the preexisting-condition requirement that we have in the existing bill, then obviously I would object to that."
It's not yet clear whether Cruz's proposal would be allowed under arcane Senate rules that Republicans are using to pass their bill with a simple majority rather than the supermajority required of most legislation. It's also unclear what the impact would be on coverage levels or the deficit. The CBO is reviewing it along with other proposed changes, according to Republicans familiar with the situation. To some in McConnell's orbit, Cruz is taking a risk by waging such a public campaign for his measure before those aspects are determined.
Cruz stands to be left responsible for the success or failure of a conservative amendment that could alienate other Republicans or undermine the special protections allowing the bill to pass along GOP party lines.
A Cruz spokeswoman did not respond to a request for comment Friday.
GOP leaders are also trying to win the support of Mike Lee, R-Utah, and Ron Johnson, R-Wis., two Cruz allies who also opposed the draft legislation.
Inside the West Wing, Trump associates are working closely with McConnell's legislative aides to track Republican senators. White House legislative director Marc Short speaks regularly with McConnell chief of staff Sharon Soderstrom and with GOP Senate leaders to hear their concerns, according to two Republicans involved in the discussions.
But while the relationship between the White House and McConnell's operation has been tight, it is far from the only nexus driving the process.
Other influential White House figures, such as chief strategist Stephen Bannon, have their own networks of friendly lawmakers and aides on Capitol Hill, at times vexing the McConnell orbit as it tries to hold together the Senate Republican conference. Bannon, for instance, has built a strong rapport with Rep. Mark Meadows, R-N.C., the chairman of the House Freedom Caucus, who is known for telling the White House what could or could not pass muster among his colleagues in the House even as the Senate leadership toils over the bill.
McConnell's proposal to work with Democrats if things fall apart could be an equally stiff challenge, given the intense partisanship that has gripped lawmakers in recent years. Nevertheless, some Republicans are hopeful.
Murkowski said she has personally contacted Democrats to see whether they might be more willing partners in fixing the health-care system in a way that fits the needs of her state. She is one of a number of rank-and-file Republicans who are warming to the idea of abandoning plans for repeal and working with Democrats to fix the existing system.
This week, Sen. Susan Collins, R-Maine, another critic of the GOP bill, said she had also been in contact with Democrats who say they are waiting for McConnell to abandon repeal so they can move on to work with moderate Republicans on bipartisan health-care legislation.
"I had one Democratic senator call me last Thursday morning at 6:54 a.m. and say to me, 'I really want to negotiate, but until this bill fails I'm prohibited from doing so,' " Collins said in an interview.
McConnell's troubles have spread in recent weeks from the roughly half-dozen early GOP skeptics on either ideological flank. Even reliable leadership allies such as Sen. Jerry Moran, R-Kan., have raised questions about the bill. Moran was the only Republican senator to face constituents at an unregulated town hall meeting this week, and he found himself flooded with voters demanding that he not support the Senate bill.
"I think there are many senators - more senators than are having town hall meetings - more senators out there who have genuine concerns with this legislation," Moran told reporters after the meeting.
David Weigel in Palco, Kan.; Kyle Hopkins in Homer, Alaska; and Murray Carpenter in Eastport, Maine, contributed to this report.