A final GOP effort to dismantle the Affordable Care Act burst into view this week in the Senate, where leaders began pressuring rank-and-file Republicans with the hope of voting on the package by the end of the month.
The renewed push comes nearly two months after the last effort to overhaul the law known as Obamacare failed in a dramatic, early-morning vote, dealing a substantial defeat to President Donald Trump and Senate Majority Leader Mitch McConnell, R-Ky., and prompting many to assume the effort was dead.
The latest proposal would give states control over billions in federal health care spending, repeal its key mandates and enact deep cuts to Medicaid, the federally funded insurance program for the poor, elderly and disabled. It would slash health care spending more deeply and likely cover fewer people than the July bill that failed because of concerns over those details.
The appearance of a new measure reflected just how damaging Republicans viewed their inability to make good on a key campaign promise of the past seven years - to "repeal and replace" former President Barack Obama's signature domestic policy achievement.
But trying again brings its own perils. It remains far from certain that McConnell can marshal the 50 votes he needs to pass the measure. Already under fire from Trump for falling short in the earlier effort, McConnell's standing with the president and other Republicans could suffer even more if he fails again.
Even Republicans who support the bill, including chief sponsors Bill Cassidy, R-La., Lindsey Graham, R-S.C., Dean Heller, R-Nev., and Ron Johnson, R-Wis., acknowledged the uncertainty of the moment. And McConnell has not committed to bringing the bill to the floor.
"I just told Bill Cassidy he's a grave robber," said Sen. John Thune, R-S.D., one of McConnell's top lieutenants. "This thing was six feet under, and I think he's revived it to the point where there's a lot of positive buzz and forward momentum. But it still comes down to, in the Senate, getting 50 votes."
Still, the fresh flurry of activity marked the most serious attempt since the failed July vote to revive the seven-year Republican pledge to undo a law that has been vilified on the right. Among those joining the effort is Vice President Mike Pence, who has been making calls to Republican senators and governors in support of the bill, according to a senior administration official granted anonymity to describe the vice president's private talks.
Part of the hurry results from the need to act before Sept. 30, when procedural rules expire that allow the Senate to pass legislation related to taxes and spending with a simple majority - and without any Democratic votes.
For McConnell, the path forward is a politically perilous. His relationship with Trump has grown toxic since the July vote - prompting the president to approach leading Democrats to discuss a tax-code overhaul as well as a potential deal protecting undocumented immigrants brought to this country as children.
Another failure for McConnell could embolden Trump - and Democrats - to continue working with each other.
But if the embattled Senate leader can shepherd a health care bill to passage, sending the effort to fulfill a core Republican promise over to the House of Representatives, he could set himself on a path to restoring his footing in other talks. Such an outcome could also help Republican senators facing reelection in 2018 who are coming under increasing attacks from insurgent conservative challengers over the failure to repeal Obamacare.
In addition to the political turmoil, the unexpected return to health care legislation has put the nation's insurance industry in a state of uncertainty. After concluding that the effort was all but dead in July, some Republicans senators reached out Democrats to shore up the insurance marketplaces created under the ACA.
Now, industry officials must once again prepare for the possibility of a fresh and dramatic overhaul.
Cassidy has stopped short of predicting that his bill will pass, telling reporters that it was his goal to write a bill that sets a marker for conservative health care policy.
"We're trying to set up good policy," Cassidy said Sunday on NBC's Meet The Press. "Whether it's done now or later, the good policy will still be there."
With Democrats united firmly against it, Senate GOP leaders can afford to lose only two of 52 Republican votes, enabling to pass the bill with a tiebreaking vote from Pence. They lost three in the July vote: Sens. John McCain, R-Ariz., Lisa Murkowski, R-Alaska, and Susan Collins, R-Maine.
None of those three committed to voting for the bill Monday, expressing reservations if not outright opposition.
"We need more information. I need to talk to the governor again," said McCain, whose home-state governor, Republican Doug Ducey, endorsed the bill Monday. Ducey had also endorsed the previous bill, so his current stance is not necessarily a clue as to what McCain will do.
McCain warned against rushing ahead. "We just need to have a regular process rather than, 'Hey I've got an idea, let's run this through the Senate and give them an up-or-down vote,'" he said.
Murkowski said she was trying to learn more about the proposal's impact on Alaska and consulting with her governor. On her way to McConnell's office Monday afternoon, she wouldn't say whether she was leaning for or against it.
Collins, who is seen by many Republicans to be the strongest opponent of replacing the ACA, said Monday that she worries that millions could lose coverage under the plan.
Adding to the challenge for Republican leaders: Sen. Rand Paul, R-Ky., said Monday that he is a firm no at this point.
"I think this is a game," Paul said. "I think this is a game of Republicans taking money from Democratic states. What happens if Democrats take power back?"
The proposal slashes health care spending more deeply and would likely cover fewer people than the July bill that failed precisely because of such concerns. Starting in 2021, the federal government would lump together all the money it spends on subsidies distributed through the ACA marketplaces and expanded Medicaid programs covering poor, childless adults living at up to 133 percent of the federal poverty level.
This approach would generally result in less money for states that expanded Medicaid under the ACA and more money for states that didn't. That's because the bill would redistribute the money allotted to the 30 states that opted to expand Medicaid under the ACA and spread it out among all 50 states.
Congress' nonpartisan budget analyst said Monday it is working to provide a "preliminary assessment" of the bill by early next week but will not estimate how the measure would affect health insurance premiums or the number of people with medical coverage until later.
The notice from the Congressional Budget Office angered Democrats, who have warned that any attempt to vote on the GOP legislation poses a serious threat to ongoing negotiations on a plan to stabilize the current health care markets and strengthen subsidies for out of pocket expenses.
Senate Minority Leader Charles Schumer, D-N.Y., dismissed the GOP plan as a way to hide a massive cut to Medicare and criticized GOP leaders for moving forward without a complete assessment of who would be covered and how much it would cost.
"It would be outrageous for our Republican colleagues to vote for this bill without knowing its effect on people," Schumer said. "That, whatever your ideology, would be nothing short of a disgrace."
Democrats have virtually no way to stop the legislation from being approved if at least 50 Republicans unite. But Schumer vowed to use every procedural tool available to create roadblocks.
Schumer also warned Monday that the renewed GOP repeal push could upset talks between Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander, R-Tenn., and the committee's top Democrat, Sen. Patty Murray, D-Wash., to offer a different approach that could pass the Senate with votes from both parties.
Even if the bill passes the Senate, it faces an uncertain outlook in the House.
"It's too early to tell whether all the Freedom Caucus guys will be supportive or not because we don't know what amendments will get added to the Senate bill," said Rep. Mark Meadows, R-N.C., the chairman of the House Freedom Caucus. The bill could also meet resistance from Republican members from states that expanded Medicaid, given the sweeping changes it proposes.
Republicans are on a tight deadline to vote before Sept. 30 if they hope to avoid being blocked by Senate Democrats. Senate budget rules allow some tax and spending measures to pass with 51 votes, instead of the 60 needed for most legislation - meaning the 52 Senate Republicans could pass a bill on their own. But those rules, which were written specifically to enable the health care law, expire at the end of the fiscal year, and GOP leaders hope to write next year's rules to focus on hoped-for changes to the tax code.
McConnell did not mention the health care push when he opened Senate business Monday afternoon.
"We're having a serious discussion, but it's still preliminary," said Sen. Sen John Cornyn, R-Texas, McConnell's top deputy.
Asked how the process of securing votes was going, he replied: "That's one of the things I'm not talking about."
The Washington Post's Paige Winfield Cunningham, David Weigel, Abby Philip, Mike DeBonis and Elise Viebeck contributed to this report.