Scrambling to round up votes to roll back the Affordable Care Act, House Republican leaders made a series of last-minute changes late Monday to their Obamacare repeal bill ahead of this week's vote.
The changes, which senior GOP leaders hope will sway wary conservative and moderate lawmakers, are aimed at building momentum for House passage while punting more substantive fixes to the Senate.
President Trump planned to come to Capitol Hill on Tuesday morning to rally House Republicans to close the deal.
"I'm optimistic the legislation not only passes the House in a strong way, passes the Senate, gets to the president's desk soon," said Rep. Kevin Brady (R-Texas), one of the bill's authors.
It was unclear whether the changes being discussed would be enough to satisfy conservatives still angry that the repeal legislation preserves major parts of Obamacare or the growing number of centrist GOP lawmakers who have voiced concerns about how many people are scheduled to lose coverage.
"While I've been in Congress, I can't recall a more universally detested piece of legislation than this GOP healthcare bill," tweeted Rep. Justin Amash (R-Mich.).
To win over conservatives, House GOP leaders are proposing to give states new authority to limit who qualifies for Medicaid, the government health plan for the poor, and impose work requirements for some aid recipients.
And to appeal to moderates, the amended legislation would provide additional assistance for Americans nearing retirement who rely on insurance marketplaces created through Obamacare, as the healthcare law is often called.
These 50- and 60-year-old consumers were scheduled to see huge premium increases under the original Republican plan, which independent analyses concluded would force many to go without coverage.
House Speaker Paul D. Ryan (R-Wis.) said over the weekend that "we have to have more assistance" for those Americans.
The changes unveiled Monday night do not specify what the additional assistance will look like, however, and the proposal would call for the House to effectively let the Senate decide.
"We're exploring different options and listening to members about how best to help that population," Brady said. "There'll be a partnership with the Senate going forward on this."
In an echo of the kind of back-room deals that Republicans accused Democrats of using to pass Obamacare, the amended House plan also includes an arcane provision designed to win over wavering GOP lawmakers from upstate New York that would specifically require the state to pay some Medicaid costs currently borne by rural New York counties.
The revisions do not include any provisions targeting high drug prices, even though Trump told a rally in Louisville on Monday night that the bill would.
Republican leaders have worked frantically over the last several days to tweak the plan to gain broader support.
But as they did, parallel negotiations were underway at Mar-a-Largo, the president's estate in Florida, where Sen. Ted Cruz (R-Texas) and a small group of conservatives, including the House Freedom Caucus' Rep. Mark Meadows (R-N.C.), huddled with administration officials.
Cruz also met Monday afternoon at the White House with other Republican senators.
The competing efforts showed the difficulty facing Ryan and Senate Majority Leader Mitch McConnell (R-Ky.) as they try to unite Republican factions around an alternative healthcare plan.
Potentially adding to the challenge, a group of 87 leading physician and patient groups — including the American Lung Assn., March of Dimes and American Academy of Pediatrics — on Monday sent a letter to Ryan and McConnell warning that the Medicaid changes in the House legislation "would leave millions without the healthcare they rely on."
The full effect of the changes on patients remains unclear, as the nonpartisan Congressional Budget Office hasn't completed an analysis of the amended GOP plan. GOP leaders said they expected an update from the budget office before Thursday's vote.
Wavering lawmakers were also hit with stern warnings from leaders that their votes would be noted by powerful conservative interest groups such as the National Right to Life Committee and the National Retail Federation.
"These next few days could define us for years to come," wrote GOP Whip Steve Scalise (R-La.) in a memo to his team responsible for rounding up votes.
The original House GOP bill was projected to nearly double the number of people without health coverage over the next decade, increasing the ranks of the uninsured by 24 million.
Millions of consumers would also see skimpier health coverage and higher deductibles under the Republican plan, the budget office projected.
And although average premiums for those who buy their own insurance are projected to be lower after 2020 than under Obamacare — partly because plans will cover less — many consumers will pay more over the next few years than they would under the current law.
Hardest hit in the long run would be lower-income Americans and those nearing retirement, according to the budget office, which estimates that over the next decade, the GOP legislation would cut about $1 trillion in federal healthcare assistance to low- and moderate-income Americans.
Obamacare is credited with extending coverage to more than 20 million previously uninsured Americans and driving the nation's uninsured rate to the lowest levels ever recorded.
House Republican leaders have been looking for ways to relieve the burden on older consumers by increasing subsidies, Ryan said Sunday on Fox News.
The original GOP legislation slashed assistance for these Americans, allowing insurers to charge them more while simultaneously making smaller insurance subsidies available to them.
That would have forced some to pay several thousand dollars more each year for health coverage, according to the CBO and other analyses. An average 64-year-old consumer making $26,500 would see a nearly $13,000 premium hike under the GOP plan, the budget office calculated.
"We have to do something about the fact that the House bill disproportionately affects older, rural Americans," Sen. Susan Collins (R-Maine) said over the weekend, a view increasingly shared by her colleagues.
The Medicaid changes under discussion in the House seem aimed at winning over reluctant conservative lawmakers, many of whom sharply criticized the original GOP legislation as maintaining too much of the original healthcare law.
House leaders are now proposing to give states extra federal aid if they impose work requirements on so-called able-bodied adults who receive Medicaid health benefits.
"Work is a blessing," said Rep. Andy Barr (R-Ky.), who gave his support to the bill after Trump told conservatives last week he backed their Medicaid changes. "It gives folks a sense of purpose, self-worth and an opportunity for upward mobility."
Many Republicans say such a requirement is necessary to prevent abuse of the program, although research indicates that the vast majority of Medicaid recipients who can work are doing so.
House Republicans are also considering yet another change in how the federal government supports state Medicaid programs.
The original House Republican plan would have cut billions of dollars in federal aid now available to states through Obamacare. That aid allowed a major expansion of coverage to low-income childless adults, a population that traditionally was not covered by Medicaid.
In place of that system, Republicans are proposing to cap how much the federal government provides states, linking future aid to how many people are enrolled in Medicaid.
The revised plan would provide states with another funding choice, which would not be tied to the number of Medicaid enrollees. The budget office projected that Republicans' original proposal would force states to dramatically scale back their safety nets, resulting in 14 million fewer people covered by Medicaid by 2026.
8:45 p.m.: This article was updated with details on the proposed amendments.