Congressional Republicans are stymied over health care. But after seven years of promising to repeal and replace former President Barack Obama's law, they risk political disaster if they don't deliver.
Republicans anticipate a major backlash from GOP voters if they don't make good on the promises that swept them to control of the House and Senate and helped propel Donald Trump to the White House in last year's elections.
Trump himself could turn on his congressional allies if they fail, some Republicans fear, and take his supporters with him just as the 2018 midterm elections loom.
And, passage of health care legislation would set the stage for the next major item on Trump's to-do list: rewriting the loophole-ridden U.S. tax code. Republicans are counting on the nearly $1 trillion in tax cuts in the health care bill to allow them to write a new tax code that raises less money.
Perhaps most importantly, after making it through six months without a single marquee legislative achievement, health legislation now looms as a make-or-break test of the GOP's ability to govern now that it controls the levers of power in Washington.
"I think it is an absolute imperative that they get health care done," said Josh Holmes, former chief of staff to Senate Majority Leader Mitch McConnell of Kentucky.
After making "Obamacare" repeal a core campaign promise, "it is deeply ingrained in the primary electorate, and failure to address it will be extremely difficult to justify," Holmes said. "I also think that governing is going to be on the ballot, and even beyond the specifics of the health care issue, the ability to get difficult things done is something that Republicans have taken pride in."
GOP senators are keenly aware of such considerations following McConnell's decision to cancel votes planned for this week on his bill to repeal core elements of Obama's Affordable Care Act. Yet even with a need to act, the gap between moderates and conservatives in McConnell's caucus looks extremely difficult to bridge. Moderates like Sen. Susan Collins of Maine view McConnell's bill as overly harsh in stripping health insurance from millions, while conservatives like Sen. Mike Lee of Utah think it doesn't go far enough in repealing Obama's law in full.
Navigating between those two poles requires a delicate balance that looks elusive for now.
And with a narrow 52-48 majority in the Senate, McConnell can lose only two Republican senators and still pass the bill, with Vice President Mike Pence casting the tie-breaking vote. Democrats are unanimously opposed.
McConnell and Pence were negotiating with individual senators Thursday in search of a deal, including adding money for opioid treatment aimed at luring Sen. Rob Portman of Ohio. McConnell hopes to bring reworked legislation up for a vote after the July 4 recess. "We know that we cannot afford to delay on this issue," he said.
The House passed its version of the health bill in May, after its own near-death experience when the bill was pulled from the floor short of votes, but subsequently revived. Leaders in both chambers hope to send a final compromise bill to Trump before Congress' annual August recess, then move on to other issues.
House Speaker Paul Ryan, speaking Thursday to WISN radio in home-state Wisconsin, called the Senate process "deja vu all over again," adding: "We just want them to get it right, and I have confidence that they can."
In addition to tax legislation, lawmakers face looming deadlines on must-pass budget bills and will have to raise the government's debt limit or face an unprecedented default.
"There's a sense of urgency to get this done," said Sen. David Perdue, R-Ga. "You've got the debt ceiling, you've got a budget, you've got to appropriate for FY18, and then you've got the tax deal — and all that has to happen this year."
But even as they face powerful incentives to act on the health legislation, for some GOP lawmakers the disincentives are just as strong.
The GOP bill, which would eject 22 million people from the insurance rolls over a decade, polls poorly, while Obama's law has grown steadily more popular. Democrats are convinced that the health care issue will be a political winner, and they're practically salivating at the prospect of using it against Republicans in the midterms.
Most medical groups are lined up against the GOP legislation, including hospitals, which are major employers in many districts. The AARP opposes the bill, as do a number of GOP governors, including Nevada's popular Brian Sandoval, John Kasich of Ohio and Maine's Paul LePage. The cuts in Medicaid funding contained in the bill coincide with the opioid epidemic ravaging some areas of the country, including in states like West Virginia and Ohio, where vulnerable residents rely on government health coverage.
These factors and others have pushed senators like Portman and Dean Heller of Nevada, who faces a tough re-election campaign, into opposing the bill.
It remains to be seen whether those lawmakers and others will get to "yes," and allow the GOP to make good on seven years of campaign promises, with all the risks and rewards that might bring.
"I don't know what happens next. I just think it can be improved, and I hope it will be. I've made my points clear for several months now," Portman said, adding: "It's tough to get 52 of us moving in the same direction."
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