Will Trump seal the healthcare deal?

It’s time for Donald Trump, the man who bills himself as the consummate dealmaker, to flex his negotiating muscle – or else.

The American Healthcare Act, which rolls back portions of the Obamacare health-insurance reforms, is scheduled for a vote in the House of Representatives on Thursday, and at the moment it’s far from certain that there are the 215 votes necessary for passage.

According to the latest media reports on vote counts, there are 29 Republicans currently in the "no" column. Assuming all the Democratic lawmakers present stick together – which seems fairly certain at this point – it would only take 23 Republican defections to sink the bill.

On Tuesday morning the president was on Capitol Hill, to make his final push to rally support for the bill. He reportedly told Republican lawmakers that a loss was "not acceptable" and went with a traditional carrot-and-stick approach.

Vote yes, and Republicans could pick up as many as 10 Senate seats in the midterm elections next year. Send the legislation down to defeat, however, and their congressional majorities were in peril.

"Many of you came in on the pledge to repeal and replace Obamacare," Mr Trump said. "I honestly think many of you will lose your seats in 2018 if you don’t get this done."

If that wasn’t clear enough, Mr Trump pointed to Congressman Mark Meadows, leader of the recalcitrant group of libertarian-leaning conservative congressmen known as the Freedom Caucus: "I’m going to come after you, but I know I won’t have to, because I know you’ll vote ‘yes’."

Press Secretary Sean Spicer would later say that Mr Trump meant that as a joke, but in politics a joke is often a threat delivered with a smile.

Mr Meadows, by the way, is still a solid no.

Meanwhile, House Speaker Paul Ryan, whose reputation as speaker is being put to his first big test this week, was talking up the president’s prowess.

"President Trump was here to do what he does best, and that is to close the deal," he said.

The president as the "closer" has been the theme of the week. Spicer said it on Wednesday, as did Congressman Greg Walden on Monday.

"He knows how to put this together," said the House Energy and Commerce Committee chairman, who helped shepherd the repeal legislation onto the House floor. "He’s got great negotiating skills, and we’re coming together with it."

All of this underlines what is at stake for the president, Mr Ryan and the rest of the Republican Party leadership. In Washington, power begets power. Successfully wielding it makes you stronger, while failure reveals weakness and engenders future failure.

The White House and the speaker have put their reputations on the line, and a loss on Thursday night would force them to restart the entire healthcare repeal process. Not only that, it would delay work on the rest of their legislative agenda, including tax reform – a heavy political lift on its own – and an infrastructure bill.

The Republicans had set out an ambitious schedule for passage of the healthcare bill, with a Senate vote expected as early as next week. Any delay will probably push a final bill, if it can be achieved, well past the Easter congressional recess.

That’s why Spicer said during his Wednesday afternoon press briefing that victory was Plan A and there was no Plan B.

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What’s in the Republican healthcare bill?

That should be of little comfort to rank-and-file Republicans in the House, who find themselves in a tricky position. Several conservative groups are putting this bill in an unwelcome spotlight, taking note of how lawmakers vote for their end-of-year legislative scorecards.

The anti-abortion Right to Life will give positive marks for a yes vote, as will the evangelical Faith and Freedom Coalition. Grassroots conservative groups Americans for Prosperity and the Heritage Action Fund, on the other hand, have said they will make no a "key vote".

In other words, House Republicans are going to hurt themselves one way or another on Thursday night. They face the unpleasant task of determining the course of least pain.

Mr Ryan has been doing what he can to sweeten the pot for disgruntled legislators – although that has often resulted in the bill being stretched in different directions, like so much legislative taffy. How far can the speaker pull it before it breaks?

Conservatives have been offered an acceleration of Obamacare tax rollbacks, the ability to add work requirements for the able-bodied poor on Medicaid and the ability for states to receive Medicaid money in block grants to do with as they please.

Moderates were given the promise of a $75bn fund to help older low-income individuals pay insurance premiums.

Then there are the handouts designed to mollify specific groups, like the provision on Medicare reimbursements crafted for New York Republicans.

Congressman Chris Collins says the deal will win the support of his state’s delegation and make them "untouchable" when running for re-election next year, according to Bloomberg’s Steven Dennis.

Such legislative arm-twisting is standard practice in Congress, of course. Democrats engaged in a similar manoeuvres during Obamacare’s oft-tortured passage. No matter how sweet the deal, however, it may not be enough to save a legislator if things go south.

Back in 2009, Louisiana Senator Mary Landrieu had a particularly choice bit of financial help packaged into the healthcare legislation to win her support. This "Louisiana Purchase", as Republicans mockingly called it, won the senator’s vote – but it did little good. She lost her seat in the first Obama-era midterm election bloodbath.

Despite all the drama, as far as bars for presidential success go, the House vote is a relatively low one. The speaker and his leadership team wield extraordinary power to shape the rules of debate in their favour and the amount of pressure they can bring to bear on individual members is great.

If indeed the number of probable Republican "no" votes that need to be flipped can be counted on one’s fingers, Mr Trump and Mr Ryan have a reasonable shot at pushing the bill across the finish line, although there may be some tense moments on Thursday night.

There’s also the possibility that if, as the hour of the vote approaches, its prospects appear to dim, uneasy House members will rush to the exits. On Wednesday afternoon, for instance, several moderate Republicans unexpectedly came out against the bill. Such is life on the knife’s edge.

While failure here would be a disaster for the White House, exposing the president as a paper tiger and the speaker as being at the mercy of his rebellious caucus, a victory only clears the way for tougher challenges in the days to come.

The efforts to appease hard-line conservatives in the House will probably rankle Republican moderates in the Senate, some of whom – such as Susan Collins of Maine and Lisa Murkowski of Alaska – are already on the record saying the original Medicaid cuts were too steep.

A handful of hard-line conservatives have also voiced their opposition.

With only a two-vote majority in that chamber, three Republican defections will sink the bill (and that number drops to two if Georgia Senator Johnny Isakson, a reliable yes vote, can’t quickly recover from back surgery).

Senate passage, which looks tenuous at best, would then probably be followed by an attempt to reconcile major differences in the House and Senate bills, and then another round of votes in both chambers to approve the resulting compromises.

After that, congressional leadership promises another piece of legislation with more substantive changes to the US healthcare system, such as paring back mandatory insurance coverage guidelines and allowing individuals to purchase from out-of-state insurance providers. Those measure will require 60 votes in the Senate to break a near-certain Democratic filibuster.

In other words, it won’t get any easier from here.

As the president might say, who knew legislating could be so complicated?