It's D-Day for Republicans in their epic quest to kill Obamacare.
The vote heralds a moment of massive political significance, especially for President Donald Trump, who is desperate for a win after a torrid first two months in power.
Trump would finally register a significant legislative win -- something he still lacks nearly two-thirds of the way through his First 100 Days. A victory on health care, along with the likely confirmation of his Supreme Court pick Neil Gorsuch in the coming weeks, would boost a White House that is increasingly under siege.
(Both Trump and Ryan have) used persuasion and threats in the tense hours running up to the vote, focusing especially on the members of the ultra-conservative House Freedom Caucus who believe the "American Health Care Act" does not go far enough to eradicate former President Barack Obama's prized domestic political achievement.
But each concession made to the conservatives made the votes of moderate Republicans who are beginning to peel away from the bill even more elusive.
Trump was piling fierce pressure on holdout lawmakers late Wednesday night in a blitz of telephone calls, as Ryan's negotiators tried to woo the Freedom Caucus with changes to the bill.
One proposal would pull the list of essential health benefits, like maternity and pediatric care and prescription drug coverage, out of the measure -- a move that would risk making it even more unpopular with moderates.
Trump told Republican lawmakers on Capitol Hill this week that they could lose their seats and GOP majority if they fail to repeal Obamacare. Ryan has praised the President's political engagement.
But as they work to finally jam the bill through the House, GOP leaders and the White House say that though they are hopeful, there is no Plan B.
"We've got a promise to keep. We promised the American people we would repeal and replace this law. We have to do it for real, not for fake, for real," Ryan told conservative talk show host Hugh Hewitt on Wednesday.
Surveying the dramatic deal-making taking place on Wednesday, GOP Rep. Tom Cole told CNN: "There's a certain amount of gamesmanship going on here -- a little bit of chicken."
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