President Trump and Republican leaders have joined a revived push to roll back the Affordable Care Act as lawmakers faced a critical deadline next week and efforts to reach a bipartisan compromise appeared to collapse.
But it was still unclear Tuesday evening whether Trump and his Senate allies would secure the votes to finally pass the sweeping legislation, which would not only scrap the 2010 law but also restructure — and possibly terminate — hundreds of billions of dollars of federal healthcare funding.
Senate Majority Leader Mitch McConnell (R-Ky.) declined to commit to scheduling the vote even after Trump personally called senators and Vice President Mike Pence told them that now was the time to act.
Further complicating the new GOP repeal push, more Republican governors Tuesday came out against the bill sponsored by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), joining a growing list of patient advocates, hospitals and physician groups opposed to the measure.
"We ask you to support bipartisan efforts to bring stability and affordability to our insurance markets," a bipartisan group of 10 governors, including four Republicans and an independent, wrote in a letter to Senate leaders.
"Legislation should receive consideration under regular order, including hearings in health committees and input from the appropriate health-related parties," the governors wrote.
They urged lawmakers to instead back a bipartisan effort in the Senate Health Committee to stabilize insurance markets.
But by Tuesday evening, that bipartisan effort appeared to be collapsing. Sen. Lamar Alexander (R-Tenn.), the chairman of the Health Committee, said Republicans and Democrats have "not found the necessary consensus." The top Democrat on the committee, Sen. Patty Murray of Washington state, said she remained confident the panel could reach a deal with continued negotiations.
Among the governors signing the letter was Bill Walker of Alaska, an independent whose position is likely to influence Sen. Lisa Murkowski (R-Alaska). Murkowski was among three GOP senators casting crucial votes to kill the last repeal bill.
But some Republican governors, including Doug Ducey of Arizona, have backed the Graham-Cassidy bill, which could have bearing on Arizona Sen. John McCain, who also voted against the earlier legislation.
In a sign of the urgency Republicans feel, Pence flew back to Washington on Tuesday from the United Nations General Assembly in New York to meet with GOP senators at the Capitol.
"This is the moment," Pence said. "Now is the time."
House Speaker Paul D. Ryan (R-Wis.) made clear earlier Tuesday that House Republicans would not support the bipartisan Senate effort, further narrowing the options for those hoping for an alternative to the Graham-Cassidy bill.
Ryan said the House instead was ready to approve the Cassidy-Graham bill.
"He told me, 'You pass it there, we'll pass it here,'" said Graham, recounting a phone call with the speaker.
The centerpiece of the Graham-Cassidy bill is a new system for distributing hundreds of billions of dollars of federal money that would restructure how the government provides healthcare assistance to some 80 million Americans.
That would represent the nation's largest change in the way healthcare is financed in more than half a century.
The bill would end both the current Medicaid program, which covers poor Americans, and the system of insurance subsidies made available by the 2010 healthcare law to help low- and moderate-income consumers buy health plans.
In place of these programs, the federal government would give states blocks of money to redesign their healthcare safety nets as they see fit.
The expanded flexibility would allow states to create better programs that cost less, Graham and Cassidy have said.
But groups representing patients, doctors, hospitals and others in healthcare warn that the looser rules would also let states drop crucial protections in the current law, such as the ban on insurers charging more to people with preexisting medical conditions.
The new system in the Graham-Cassidy bill would also mean huge cuts in funding for many states, including California, and an end to federal healthcare aid for states after 2026 unless Congress acts to continue the assistance.
"We believe the Graham-Cassidy amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care," American Medical Assn. Chief Executive James L. Madara wrote in a letter to Senate leaders Tuesday.
No leading patient or healthcare groups support the Graham-Cassidy proposal.
It is also becoming clear that the legislation will receive almost no scrutiny before senators are possibly called to vote on it next week.
The nonpartisan Congressional Budget Office has said it will not have time to fully analyze the bill's impact on health coverage and insurance premiums.
And the bill will get only one hearing, which Senate Finance Committee Chairman Orrin G. Hatch (R-Utah) has scheduled for Monday.
By contrast, the 2010 healthcare law, though passed in haste at the end, was developed over more than 15 months, with scores of committee hearings, testimony from experts, independent analyses and weeks of debate on the floors of the House and Senate.
But after seven years of promising to repeal that law, Republicans are under intense pressure from conservative activists, who are angry at the GOP-led Congress for failing to deliver on a top campaign promise, and leaving Trump with few options but to reach across the aisle, as he has done in recent weeks, to make deals with Democrats on other issues.
As senators left a private lunch meeting Tuesday, several reasoned that the legislation may not be perfect, but it's better than sticking with Obamacare.
"This is the last best chance for putting ourselves back on a path where states get greater control and we can start improving our healthcare system," said Sen. Ron Johnson (R-Wis.). "I think if we bring this up on the floor, I think every [Republican] senator is in play."
But key Republicans — including Murkowski, McCain and Sen. Susan Collins of Maine — have yet to give their support.
Others, including Sen. Dean Heller of Nevada, a coauthor of the Graham-Cassidy legislation and one of the most endangered GOP senators up for reelection next year, are fully on board. But Heller's position is at odds with his state's Republican governor, Brian Sandoval, who signed the governors' letter Tuesday opposing the bill.
Even though Ryan suggested the bill would find support in the House, that is no guarantee. The conservative House Freedom Caucus has been working with the senators, but Ryan had great difficulty assembling a majority for earlier Obamacare votes.
Graham said he was optimistic, in part because he had entered into an unusual alliance with "Darth Vader" — a joking reference to Stephen K. Bannon, the former Trump advisor and Breitbart News editor who is backing the bill.
Democrats appear poised to hold a unified front against the bill, despite Republican warnings that it would be tough for senators to oppose legislation that could bring more money to their states.
Sen. Dianne Feinstein (D-Calif.) called it "appalling" that Republicans would take federal funds that provide healthcare to Californians and give them to Republican-leaning states. She pledged to "do all I can to defeat this terrible bill."