Seven years of Republican promises to replace Obamacare will be kept alive or dealt apotential death blow Thursday in a dramatic House vote on anembattled health bill, with big political risks for PresidentDonald Trump and Speaker Paul Ryan.

House leaders and administration officials expressedconfidence Wednesday night that they have just enough votes topass the measure, which is set for an early-afternoon vote inWashington. But with a number of GOP moderates still voicingreservations about the bill, Ryan and other party leaders have arazor-thin margin of error.

“Would you have confidence? We’re going to pass it,” House Majority Leader Kevin McCarthy ofCalifornia told reporters Wednesday night.

The sudden enthusiasm belied the past six weeks of gut-wrenchinguncertainty over the fate of the GOP health-care bill, whichfeatured intense pressure from Trump and his top aides to hold thevote, despite doubts about the depth of support.

The success -- or failure -- of the GOP’s vote will be the mostsignificant test yet for both Trump and Republican leaders inCongress, who have very little to show by way of legislativeaccomplishments so far this year.

220 votes

On Wednesday night, the Trump administration projectedconfidence about the outcome. At a White House dinner withreligious leaders, a Trump aide joined the dinner late, saying thecount had reached 218, two more than needed to guarantee passage.The aide added that he thought the final tally would top 220 votes,according to two people who attended.

“We’re going to bring premiums down” and “get insurers back intothe markets,” Representative Greg Walden, a Republican from Oregon,told MSNBC on Thursday morning. Walden was one of a handful oflawmakers who met with Trump on Wednesday about an amendment thatwould add $8 billion to help insure people with pre-existingconditions, a measure designed to encourage more lawmakers to votefor the bill. “I think we’re on the right track here.”

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Even if the bill manages to pass the House, it faces a verytough road in the Senate. At least eight Senate Republicans arestrongly opposed to different elements of the measure, which alsofaces potential procedural hurdles.

Representative Alcee Hastings, a Democrat from Florida, warnedRepublicans during a House Rules Committee meeting to expectchanges to the bill if it is taken up in the Senate.

“I think they take health security a little more seriously andit’s a more moderate body than we are, and so you can reasonablyexpect that when you pass this tomorrow on the slimmest of margins,you shall not see it again, and you will not see it in the formthat it’s in,” Hastings said Wednesday night.

House GOP leaders would be relieved to hand off the Obamacarerepeal challenge to the Senate, given the excruciatingback-and-forth of the past few weeks. In late March, Ryan and Trumphad to abruptly scrap a planned vote on an earlier version of themeasure with less than 24 hours’ notice, after counts showed itheaded to a defeat.

‘Law of the land’

That led Trump -- who made repealing Obamacare a cornerstonecampaign promise last year -- to lash out at House members in thearch-conservative House Freedom Caucus for not supporting thatbill. The embarrassment also was intense enough for even Ryan toaccept publicly afterward that Obamacare remained “the law of theland for the foreseeable future.”

But Ryan and his lieutenants decided to try it again, aftermembers were bombarded by phone calls from Trump and negotiatedamendments with senior administration officials, including VicePresident Mike Pence.

Since no Democrats are expected to back the bill, Republicanscan only lose 22 Republicans if everyone in the House casts avote.

“I think everybody’s still wondering, do we really have thevotes?” Representative Daniel Webster of Florida said Wednesdaynight. Undecided for weeks, he said late Wednesday that he’d backthe bill.

Webster’s own decision to back the bill was late in coming, onlyafter he said he got assurances his concerns would be addressedabout future funding for his state’s Medicaid-funded nursing homebeds.

But far bigger developments have helped change the landscapefrom March’s vote scuttling. The biggest shift came two weeks agowhen conservatives who had been insisting for a full Obamacarerepeal said they’d accept amendment language that would allowstates to apply for waivers from some Obamacare regulations.

Pre-existing conditions

One of those waivers applied to pre-existing conditions -- to allow state toapply for waivers to let insurers in their jurisdictions chargepeople with pre-existing conditions more if they have a gap incoverage. States would have to develop some method, possibly ahigh-risk insurance pool, to help sick people.

The changes won over a number of conservatives, but alienatedsome House Republican moderates. They warned the amendment couldweaken a popular protection offered by Obamacare that has helpedsick people gain insurance coverage they were otherwise denied, orcouldn’t afford.

Other lawmakers were angry that the measure was being rushedthrough the House, without any hearings. Last-minute changes werenegotiated in secret, and members were being pushed to vote beforethe Congressional Budget Office had time to offer estimates onhow the revisions would affect the cost of the measure or how manypeople would lose coverage.

“This is not the way we should operate, we’re a deliberativebody,” Democrat Jim McGovern of Massachusetts said during the RulesCommittee meeting Wednesday night. “I think the whole process andthe way this has been handled is an insult to the institution, andmore importantly it’s an insult to the American people.”

Then, on Wednesday, influential moderate Republican Fred Uptonof Michigan -- a former Energy and Commerce chairman -- reversedhis earlier opposition and embraced the bill after a meeting withTrump.

Upton told reporters that he would vote for the measure becauseTrump and the leaders said they would go along with additionallanguage he helped devise to boost funding for people withpre-existing conditions by $8 billion over five years.

Outside health-care experts suggested that $8 billion wouldn’tfill the shortfalls in the high-risk pools, but at least threeother previous holdouts signed on as co-sponsors. “Thisamendment reinforces my commitment to ensuring coverage for Iowanswith pre-existing conditions,” said Representative Dave Young ofIowa.

House Republican leaders later Wednesday were saying that hadput them within only a handful more votes needed -- and byWednesday night McCarthy was claiming the needed votes werethere.

Skeptical moderates

Even so, several influential moderates -- includingRepresentative Charlie Dent of Pennsylvania, a co-chairman of thecentrist Tuesday Group -- said they remained publiclyopposed. Moderates, many of whom come from swing-statedistricts, could pay a high political price if people in theirdistricts lose coverage.

And a wide array of industry groups and health advocatesremained opposed to the GOP measure, despite the Upton-ledchanges.

AARP, the influential lobby that advocates for older Americans,says it remains opposed to the GOP bill, posting in a tweet thatthe Upton amendment is an “$8 billion giveaway to insurancecompanies; won’t help majority of those w/preexistingconditions.”

Passage of the GOP measure is just an opening hurdle and doesn’tmean smooth sailing in the Senate. It remains well short of the 50votes it would need for passage. A number of Republican senatorsare unhappy with an earlier Congressional Budget Office estimateshowing it would result in 24 million more people without insurancewithin a decade and skyrocketing premiums for lower-income people,particularly those over the age of 50.

But those and other hurdles only loom if the bill gets to theSenate.

Defeat of the bill Thursday would not only likely put alegislative dagger in Obamacare repeal, but it also would leaveRyan in a weaker position as speaker, defied by his ownmembers.

And in a week that saw Trump fail to obtain early money in agovernment spending bill for his promised border wall between theU.S. and Mexico, he would see another campaign promisethwarted.

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