The move was a high-risk gamble for the president and the speaker, who have invested significant political capital in passing legislation that would replace the 2010 Affordable Care Act. For Trump, who campaigned as a skilled negotiator 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 be a defeat for Trump in his first effort to help pass major legislation and it may also jeopardize other items on his wish list, including a tax overhaul and infrastructure spending.
"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 presidential 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 hard-line House Freedom Caucus refused to back it following a marathon session of negotiations Thursday with Trump and other top aides.
Post-meeting, a handful of Republicans announced they would back the legislation. But a larger number said they were still opposed or had yet to make up their minds.
“For seven and a half years we have been promising the American people that we will repeal and replace this broken law, because it’s collapsing and it’s failing families,” Ryan said. “And tomorrow we’re proceeding.”
But the speaker refused to answer shouted questions from reporters after the meeting about whether he had the votes for passage.
“They’re going to bring it up, pass or fail,” said Rep. Mike Simpson (R-Idaho).
In the meeting with House Republicans on Thursday 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.”
A key moment inside the session, several lawmakers said, was when Rep. Brian Mast (R-Fla.), a freshman lawmaker who lost both his legs in 2010 while serving as an Army bomb disposal technician in Afghanistan, rose and called on his colleagues to unite behind the bill in the same way he and his comrades fought in battle.
A rowdy group of Republicans burst out of the meeting like explorers on a quest for glory. “Burn the ships,” one Republican shouted to House Majority Whip Steve Scalise (La.), invoking the command that Hernan Cortes, the Spanish conquistador, gave his men upon landing in Mexico in 1519.
The message was clear, to the GOP leaders now and the Spaniards in 1519, there was no turning back.
“Only way to do it,” Scalise told a packed elevator of lawmakers.
Leaders continued to plead with individual lawmakers to support the measure well into Thursday night, with the House Rules Committee slated to meet early Friday morning to consider the proposed changes.
Ryan got down on a knee to plead with Rep. Don Young, an 83-year-old from Alaska who is the longest-serving Republican in Congress and remains undecided.
When the speaker finished with Young, he spent about 10 minutes in an animated discussion with Rep. Mo Brooks (R-Ala.), one of the bill’s most outspoken critics. At one point, the speaker took his own arms and held them up, his hands at face level, then slowly lowered them to his waist — presumably trying to demonstrate his belief that the bill will lower costs.
The ongoing effort to whip the vote, Rep. Joe Barton (R-Tex.) said at one point, involved “back-patting and butt-kicking.”
“Democracy’s messy,” he added.
Ryan had intended to bring up his plan for a vote 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. White House Chief of Staff Reince Priebus and Trump chief strategist Stephen K. Bannon trooped up to Ryan’s office to make the case personally, warning recalcitrant conservatives that the only alternative would be to accept the ACA as the law of the land.
By evening, leaders adopted the proposed change conservatives had rebuffed earlier, eliminating the law's "essential benefits" that insurers must offer under the ACA in an effort to reduce premium costs. Those benefits include covering mental-health treatment, wellness visits, and maternity and newborn care, and states would have the option of adding them back next year.
They also added one sweetener for moderates, a six-year delay in repealing a 0.9 percent additional Medicare tax on high-income Americans who earn above $200,000 if filing individually, or $250,000 if married and filing jointly. By keeping the tax in place, GOP leaders could provide an additional $15 billion to the states to help cover treatment for mental health and substance abuse issues, as well as maternity and infant care.
Meanwhile, a new analysis by the Congressional Budget Office released Thursday evening showed that changes House leaders made to the bill 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.
But it was lawmakers on the right eager to dismantle the current health-care law who remained GOP leaders’ biggest problem.
“I’m still a ‘no’ on the bill,” said Rep. Mark Meadows (R-N.C.), who chairs the Freedom Caucus. “I think it’s the president leading, and I applaud him for leading.”
Some key moderates are also against the bill. Rep. Dan Donovan (R-N.Y.), who has known Trump for decades and whose Staten Island district swung heavily toward the Republican candidate, left the meeting committed to voting no.
“I’ve got to think about the 744,000 people I represent,” he said. Asked about the White House’s message that killing the bill would leave no more chances for repeal, he shook his head. “I don’t believe that.”
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. Speaking to a group of trucking executives and employees at a White House event aimed at showing how the ACA had driven up the industry’s costs, Trump joked that he did not have much time to mingle.
“I’m not going to make it too long, because I have to get votes,” Trump said, sparking laughter. “I don’t want to spend too much time with you. I’m going to lose by one vote, and then I’m going to blame the truckers.”
This high-wire balancing act, in which Republicans are catering to conservatives in the House with the knowledge that they still must woo moderates to get legislation to Trump’s desk, could not only reshape the nation’s health-care system but could also have uncertain electoral repercussions for the new majority.
GOP leaders can afford only 21 or 22 defections, depending on how many Democrats are present Friday.
But with failure not a viable option, Ryan and Trump have been working furiously to win over the large voting bloc of conservatives who control the House bill’s fate.
Passage of the bill would represent a major political victory for both the White House and House leaders, although the ultimate fate of the legislation hinges on the Senate. There are at least a dozen skeptics of the bill among Senate Republicans, who maintain a slim 52-to-48 advantage, and many of them want to maintain some of the current law’s more generous spending components.
Democrats relished the GOP’s predicament. Members of the Congressional Progressive Caucus, who had scheduled a 4 p.m. rally against the bill, turned it into a short-term declaration of victory.
“Remember, they wanted to have their repeal and replace ready when Trump was inaugurated,” said Rep. Jan Schakowsky (D-Ill.). “Now, here we are — they don’t have it, again. They’re looking for a sweet spot, and they won’t find one.”
Former president Barack Obama, for his part, issued a statement noting that more than 20 million Americans have gained coverage since he signed the law in 2010, while the rise in health-care costs has slowed. The statement came on the seventh anniversary of the passage of the Affordable Care Act — a day that Republicans had hoped to mark by dismantling it.
“So the reality is clear: America is stronger because of the Affordable Care Act,” Obama said, adding that Republicans are welcome to work with Democrats to improve the law. “But we should start from the baseline that any changes will make our health-care system better, not worse, for hard-working Americans. That should always be our priority.”
David Weigel, Kelsey Snell, John Wagner, Paul Kane, Ed O’Keefe and Karoun Demirjian contributed to this report.