Donald Trump had had it.
The Obamacare repeal bill that the president had just boasted was on the cusp of passage was suddenly in trouble again, and the president demanded to talk to the influential congressman who dropped a bombshell hours earlier with an announcement he’d be voting “no”: Michigan Rep. Fred Upton.
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Sitting in the Oval Office Tuesday evening, Trump dialed Upton in his congressional office. The president raised his voice and swore at Upton several times during a 10-minute conversation, sources familiar with the call said. But Upton stood his ground. He explained that he, like Trump, wanted to ensure people with pre-existing conditions were protected, even quoting the president verbatim talking about the need to do so.
“I am not supporting this bill without a legislative fix,” Upton said, according to a source familiar with the conversation.
Trump did not want to talk about the merits of the legislation — he didn’t care much about those specifics, senior officials said. What mattered to him was how a failed vote would hobble his presidency and the ability to get other legislation through Congress.
He wanted a win.
The next day, House leaders agreed to another $8 billion to help cover people with pre-existing conditions. The last-minute tweak flipped Upton and at least a half-dozen moderate holdouts, enabling leadership to nail down their final, 216th vote for a majority — and prevented the Trump presidency from a second embarrassing collapse of health care legislation in as many months.
Upton and Trump convened at the White House on Wednesday for a much more pleasant meeting. “The president was happy to sign off on their deal,” one senior administration official familiar with the meeting said. “It was all peace and love.”
Interviews with dozens of key lawmakers, congressional staffers and administration officials for this story the past few weeks revealed how the pressure of an impatient White House — and fears of repercussions for not following through on campaign promises — finally produced a bill backed by all corners of the GOP Conference, from far-right libertarian Justin Amash (R-Mich.) to vulnerable swing-district Republican Darrell Issa of California. But while GOP leaders welcomed the White House’s assistance in trying to win over conservatives, the involvement of the president and administration this second go-round often rankled senior Republicans, who viewed it as counterproductive in many cases.
For whatever flaws in the process, though, Trump, Speaker Paul Ryan and his leadership team managed to provide the right mix of pressure and reassurance to wobbly Republicans to get the measure through. It passed the House Thursday, 217-213, and now heads to the Senate for a likely makeover.
‘You need to vote!’
The Trump-Upton exchange was the culmination of a dynamic that plagued Republicans throughout their push to move legislation through the House. White House officials, including chief of staff Reince Priebus, constantly pestered Ryan to hold a vote on the bill, which they felt wasn’t moving fast enough. Their prodding enraged House GOP leaders, who say their decision to hold back stemmed from their knowledge of how the Hill works.
Leadership had to strike a delicate balance between conservatives who helped sink an earlier draft of the bill they dubbed “Obamacare lite” and moderates who could lose their seats — and possibly the House majority — if they backed the legislation.
“They kept saying, ‘You need to vote! You need to call the vote!’ But we were trying to give this space and time to develop as opposed to a pressure cooker,” said one House Republican aide. “We needed to let this play out a little bit. But the White House just couldn’t let this go.”
The day after Ryan pulled the first Obamacare repeal bill from the floor in late March, Rep. Tom MacArthur (R-N.J.) couldn’t stop thinking about how close conservatives and GOP leaders had come to an agreement at a late-night meeting with Vice President Mike Pence a few days earlier. MacArthur believed he could help find a middle ground.
The 56-year-old, second-term centrist grabbed some paper and started sketching out an amendment that would put limits on what conservatives were demanding. His proposal would allow states to opt out of some, but not all, Obamacare regulations. He took the idea to Ryan, who asked MacArthur to touch base with Rep. Mark Meadows (R-N.C.), the chairman of the hard-line conservative House Freedom Caucus.
“I just felt very strongly that there was a lost opportunity,” MacArthur said in an interview.
Many House Republicans rolled their eyes at the prospect of the two lawmakers from opposite ends of the party striking a deal. But the duo talked almost every day over a several-week stretch, even touching base on Easter. Eventually, they came up with a framework that Meadows believed could deliver 15 to 20 additional conservatives votes.
For a while, Ryan wasn’t involved in the talks, though his health care adviser, Matt Hoffmann, often was. Ill will between the Freedom Caucus and leadership had reached a boiling point, with conservatives claiming that Ryan wouldn’t listen to them and Ryan accusing the group of not understanding how to govern.
But Meadows found an ally in Pence, who stepped in to facilitate negotiations, giving them instant credibility in the eyes of Republicans inside and outside the Capitol. Pence also made calls to outside conservative groups to ensure they would back any agreement.
“The framework for a deal began when Pence doggedly worked the phones and scheduled meetings to explain the provision [allowing states to opt out of Obamacare rules] to outside groups,” said Tim Phillips, who leads Americans for Prosperity, the Koch brothers-backed group. “It needed to be someone really credible since there was no language, and that was him.”
Priebus on the hot seat
As the process unfolded, no one was feeling more heat than Priebus. After the first bill’s collapse, Trump called allies and friends to sound them out about Priebus’ abilities to perform his job, several people familiar with the calls say.
Priebus then upped his game on the health care bill. On the day Ryan pulled the original bill because it lacked the votes to pass, the White House chief of staff made a list of “no” votes he would try to turn. He also began to see his job as personally exerting pressure on lawmakers.
When the MacArthur-Meadows deal looked close to being done, Priebus called a White House meeting with Ryan and asked him to cancel a looming two-week congressional recess in order to finish the bill.
The meeting quickly went off the rails, however, when Ryan refused. He argued that members needed space before the House took another crack at repealing Obamacare.
“There will be calls for you to resign,” Priebus told Ryan, according to two people in the room. (Another source familiar with the conversation but not in the room said Priebus’ comments were not aimed at Ryan but at Republicans in general.)
In a way, it undermined his position. Other White House officials looked for ways to pressure holdouts — targeting former aides, business leaders, current lawmakers and others back in their districts who could call and pressure them to get to yes.
But Priebus’ harping on Ryan was bizarre, senior GOP aides thought. Several White House officials and Capitol Hill insiders believed they reflected a deep fear of losing his own job.
“How could you take him seriously doing that?” one of them said.
Priebus’ hounding didn’t stop there, though. In the days before the bill finally passed, he began calling members listed as “no” votes and asking them what they needed to get to yes — whether on health care or other things the administration might be able to do for them.
“The effect of not passing it hit people like a ton of bricks,” said one White House official familiar with Priebus’ plight. “We’re not going to be defeated — [it’s] not a sustainable position for us to be in, not a credible position for us to be in. We knew it was a bad position.”
The White House pressure was not helpful, GOP insiders said. Every time the White House whispered to reporters that a vote was imminent, Republican leaders would look incompetent for failing to meet the latest deadline.
In a Thursday interview in his Capitol office, Majority Whip Steve Scalise (R-La.) had only praise for Trump and the White House. He said the president was “very generous with his time,” and he applauded Pence for coming to the Hill to meet with members.
Scalise also sought to justify leadership’s timeline. They wanted more than just a show vote, he said.
“There were times when we didn’t have the votes but we wanted to vote,” he said. “We could have just voted so that everybody is on record, but the bill failing doesn’t help one family who’s getting a 30 percent increase in their health premiums next year.”
Under enormous pressure by the White House, GOP leaders became increasingly involved in the MacArthur-Meadows negotiations during the two-week Easter recess. Ryan’s health staffer, Hoffmann, helped the pair draft their amendment into legislative text.
And when the changes landed, all the behind-the-scenes haggling paid off. Meadows ended up delivering all but one member of the Freedom Caucus, a group known primarily for saying “no.”
But the handshake agreement with conservatives came at a cost for leadership. Scalise and Chief Deputy Whip Patrick McHenry started seeing centrist supporters of the original bill say they were undecided or opposed, citing the lack of protection for pre-existing conditions.
Members of the Energy and Commerce Committee also fumed that two members not on the panel that handles health care — MacArthur and Meadows — had been given authority to substantially change the bill. Even members of MacArthur’s moderate Tuesday Group turned against him and started whispering that he should step down.
GOP leaders felt the onus would be on them to smooth things over and push the deal over the finish line. The members defecting were almost entirely Ryan allies from swing-state districts won by Hillary Clinton — not Trump loyalists.
But the White House had other ideas; the president wanted to close. Trump, who initially didn’t care about health care, felt personally stung by the defeat in March, so he asked for a list of members to call almost every day. Some of the calls were acrimonious. Others were friendly.
A number of members were already leaning in favor but wanted to talk to the president before committing.
The president’s pitch was simple: If we don’t pass this, we’re going to be hurt down the road. He would also remind them that the bill could change in the Senate. And he warned lawmakers that voting “no” is just going to get them “more and more problems,” said one White House official who sat in for many of Trump’s conversations.
With the help of Pence, Trump appeared to flip at least one lawmaker who had been opposed: Mo Brooks of Alabama. The hard-core conservative had voted against the Freedom Caucus endorsement of the MacArthur deal, remaining a “no” even after the Meadows-MacArthur compromise.
So about a week before the vote, Pence called Brooks to see if there was anything he could do win him over. Brooks told him he needed more time to read the bill. Two hours later, Pence called back again, then handed his cellphone to Trump. Brooks flipped on the spot.
‘Billy’s against me?’
For the most part, however, leadership had to carry the final few Republicans across the finish line. The president spoke to dozens of members, but he didn’t quite lock them in, according to multiple House Republican sources.
That was precisely what happened with Rep. Billy Long (R-Mo.). A longtime ally of Trump’s whose daughter is being treated for lymphoma, Long also said the bill was too weak on pre-existing conditions for him to back.
Trump phoned Long a few hours after he came out against the bill on Monday, expressing his frustrations and trying to win him back.
But the call did not go well and Long remained opposed.
“Billy’s against me?” Trump asked a senior administration official, with surprise. “Billy was on the campaign!”
Long, however, came around after the changes offered to Upton were adopted.
“This White House is, in a lot of ways, like the Obama White House: Lots of talk,” said one House Republican source. “But the members who voted for this bill didn’t do it because of what they heard from the White House.”
While Trump grumbled about the changes made to appease Upton, Ryan and his leadership team saw an opportunity. They knew they had a number of moderate Republicans with the same concerns. If they could win back Upton, they figured, they might just win enough other moderates to put the bill over the top.
House GOP leaders had received a heads-up on Upton’s defection before it happened. They’d set to work to win him back right away, crafting new changes to the bill even as Trump and the White House pressured them to just take the measure to the floor.
During a Tuesday afternoon meeting in the speaker’s office, Ryan, Majority Leader Kevin McCarthy and Scalise made Upton an offer: $5 billion more to support people with pre-existing conditions. Upton rejected it, wanting more. Leaders raised their number to $8 billion, and Upton accepted.
The changes to the bill immediately won the endorsements of swing-district California Republicans Jeff Denham, who had been opposed, and David Valadao, who was undecided.
Other moderates were also reassured, giving leaders confidence that they were almost ready for the floor.
The final votes
Several GOP insiders on Capitol Hill pointed to Health and Human Services Secretary Tom Price as a helpful force within the administration. Leaders tapped him to answer technical questions and provide reassurance to members with concerns.
Rep. Daniel Webster (R-Fla.) was leaning against the bill, worried about how a cap on Medicaid beneficiaries would hurt nursing homes. GOP leaders put him in touch with Price, and after the two spoke, Webster changed his mind.
One of the final Republicans to come around was ironically moved by a massive problem with the Obamacare insurance exchanges, as Republicans have been warning about for months. The last insurer on Iowa’s exchange pulled out the day before the vote, leaving thousands without an option to purchase insurance.
That troubled Iowa Rep. David Young, who had remained opposed to the measure throughout the talks. The vulnerable Republican felt compelled to vote for a replacement in light of his home-state situation. In a meeting with Ryan, McCarthy and Scalise just hours before the vote, he delivered them the news.
The bill passed with one vote to spare.
Trump wanted to exult afterward, and dozens of members joined him for a Rose Garden celebration, taking a bus from Capitol Hill. But some White House officials were more cautious about taking a victory lap, and whether to hold the event sparked more furious debate.
As one senior administration official said: “This is nowhere near done.”