10 story lines to follow as the House votes on health care

Majority Leader Kevin McCarthy has guaranteed victory when the House votes Thursday on a health care bill that would overhaul Obamacare. "Do we have the votes? Yes. Will we pass it? Yes," the majority leader told reporters Wednesday night. The Rules Committee met late Wednesday night to take procedural steps and approve the compromises that have been made.

Some guidance on timing, via Majority Whip Steve Scalise's office: Around 10:30 a.m., the House will have its first votes of the day. Then the chamber will begin formal debate. Between approximately 1:15 p.m. and 1:45 p.m., the House will vote on this legislation. Members are being told they'll be free to leave the floor by 2:30 p.m. to 3 p.m.

What you need to know about the state of play: This vote is going to be very close, and the whipping will continue until the last minute.

House Republicans can afford to lose no more than 22 GOP votes. The running whip count that Amber Phillips has been keeping for us is fluid, but she has 20 members who are on the record saying they are opposed to or leaning no on the bill. Another 35 are undecided or refuse to say, and 23 more have switched to yes.

That leaves very little margin for error. Rep. Jason Chaffetz has even returned to D.C. after getting foot surgery in Utah - before he was supposed to travel — so that he can vote.

GOP leadership aides say they are mindful that the bill cannot pass by just one vote. They know that, if that happens, Democrats can run attack ads describing each supporter of the bill as "THE DECIDING VOTE" on a measure that remains quite unpopular. How do they know this? Because they successfully used that talking point against Democratic senators for three election cycles in a row.

Annoyingly for the strategists tasked with holding the majority, the number of Republicans with safe seats who are voting no is putting a lot more pressure on vulnerable members in swing districts to support the bill. These guys might normally get a pass because they're going to face tough races in 2018. But House GOP leaders are now calling in all of their chits.

If you want to watch someone closely Thursday, look at Colorado Rep. Mike Coffman, who represents a suburban Denver district that went for Hillary Clinton. He issued a carefully-worded statement Wednesday that give him cover to go either way and reflected the pressure he's under from all sides: "The critics of the House bill are being totally disingenuous when they say the bill dooms those with preexisting ailments. . . . But I worry that, under the current language, a small percentage of those with preexisting conditions may not be adequately protected. If House Leadership will work to tighten protections for those with preexisting conditions, I'm a yes on sending this bill to the Senate for further consideration. If not, I'm a no, and we'll go back to the drawing board to clean up the mess created by the Affordable Care Act."

Also keep an eye on Florida's Carlos Curbelo. He's close with party leadership and has grander ambitions, but Clinton carried his district — which stretches from Miami to Key West — by 16 points. "The easiest thing to do in this town is to say no," he told one of our reporters on the Hill Wednesday afternoon. "That's usually the politically expedient thing to do. If I believe this legislation can be improved by the time it comes back to the House, I will be supporting it." When a CNN reporter followed up Wednesday night, he remained undecided:

He's not alone in holding his cards very close to the vest. Presumably, a lot of members really want to vote against a bill full of fodder for attack ads. But they know they must walk the plank if leadership cannot get their colleagues on board.

Here are 10 story lines to follow today:

1. Fred Upton's compromise will get credit for salvaging the bill. The Michigan Republican gave cover for people to switch from no to yes by extracting more financial assistance - $8 billion over five years — to help people with preexisting conditions pay for medical costs.

2. From a public policy perspective, the concession to Upton may not actually help people with preexisting conditions very much. Amy Goldstein explains: "The linchpin . . . is an iffy, 'back to the future' idea for dealing with what has been an intractable dilemma . . . Leading health policy experts said the amendment raises big questions about how — and how well — it would work in practice. Among the most significant: How many states would back away from the federal protections for people with medical conditions? And how many of those people would lose their coverage because of other changes in the House plan? . . .

"A Republican House aide familiar with the amendment, who spoke on the condition of anonymity, portrayed the people who would need the extra help as 'a small, narrow group,' " Goldstein reports. "However, Larry Levitt, senior vice president of the Kaiser Family Foundation, said that the number of Americans with medical conditions and no insurance could increase under the GOP plan because the ACA's subsidies would be replaced by smaller, more restrictive ones. And, Levitt said, it is impossible to anticipate how far the amendment's money would have to stretch without knowing how many states would try to get rid of the current insurance rules. It is also unclear what would happen once the money was gone in five years."

The director of The Post's fact checking unit, Glenn Kessler, warns readers to be skeptical of promises that people with pre-existing conditions will not be hurt by the bill: "When it comes to health care, readers should be wary about claims that important changes in health-care coverage are without consequences and that people are 'protected' - or that the changes will result in massive dislocation and turmoil. There are always winners and losers in a bill of this size. In this case, if the bill ever became law, much would depend on unknown policy decisions by individual states - and then how those decisions are implemented."

3. The lack of buy-in from industry groups and other key stakeholders is making it harder to get certain wavering Republicans on board. "There aren't many local doctors, local hospital chief executives or insurance executives pushing these Republicans to vote for Ryan's bill - because their national associations all oppose the legislation," Paul Kane wrote in his column Wednesday. "This has left these undecided Republicans without many allies back home. Instead of pointing to support from local hospital officials, they're getting an earful from them about what is wrong with the legislation. . . . Republican leaders say they spent time with groups such as the American Medical Association and AARP, to no avail."

Several prominent advocacy organizations reiterated their opposition even after Wednesday's changes. The president of the American Medical Association said "none of the latest legislative tweaks under consideration changes the serious harm to patients and the health care delivery system." Millions would still lose coverage or have to pay far higher insurance costs "as a direct result," said Andrew Gurman. The AARP argued that the changes "would make a bad bill even worse," increasing out-of-pocket costs for Americans ages 50-64 and weakening the fiscal stability of Medicare, which covers people over 65.

4. The House is voting before the nonpartisan Congressional Budget Office gets a chance to estimate just how many people will lose coverage under this bill and how much it grows the deficit.

If the numbers are bad after the fact, it's not like Republicans can say they didn't know because they didn't wait to get the estimate. That excuse wouldn't wash with most voters. Initial outside guesstimates based on the details we know are not pretty.

Opening himself up to charges of hypocrisy, Paul Ryan complained in 2009 about Democratic efforts to move the health bill. "I don't think we should pass bills that we haven't read and don't know what they cost," the congressman said on MSNBC. Watch the clip:

Democrats are already seizing on the lack of a score. You'll hear a lot more comments like these two in the hours to come:

5. More broadly, Ryan's prestige is on the line. This could be a huge short-term victory for him. CNN's Stephen Collinson says the speaker will regain some of the luster he lost when he was forced to pull the bill in March: "When he failed to make good on a push to pass Obamacare repeal the first time, Ryan told reporters that moving from an opposition party, as the GOP was in the Obama years, to a governing party in control of Congress comes with 'growing pains.' A narrow vote to pass the American Health Care Act on Thursday would not represent a coming of age for the Republican majority, but it will at least restore confidence that the GOP can come together to pass an agenda that had been assumed before the health care debacle, to herald a new era of conservative governance."

Ryan has put all his cards on the table. "He has framed Obamacare repeal as a moment of truth for his party, telling rank-and-file members in a private meeting this week that what they do will 'define' Republicans for years to come," The Hill's Scott Wong and Alex Bolton note.

6. The White House also has a lot riding on this. There has been a full-court press on leadership and members to move a bill. Spotted at the Capitol just Wednesday: Vice President Pence, White House budget director Mick Mulvaney, CMS administrator Seema Verma, and Health and Human Services Secretary Tom Price.

Price makes the case for the current version of the House bill in an op-ed for CNBC: "The bill will repeal the foundation and most corrosive elements of the current healthcare law and, more importantly, take power out of Washington and give it back to patients and doctors, while providing tens of billions of dollars in additional federal help for patients with pre-existing conditions."

7. The next two weeks could be rough for Republicans, no matter how they vote. After Thursday, lawmakers return home for a two-week recess. There was a heavy push to hold the vote now because many involved in the process feared that the measure would fall apart if they waited until after May 16 when members had heard an earful from their constituents about problems in the bill. Members who vote for it will need to defend themselves back home in the coming days, and members who vote against it could face ire from conservatives in their districts who are angry that they didn't follow through on a central campaign promise.

8. The GOP civil war will continue: Some moderates are very mad at their leader for negotiating with the Freedom Caucus.

Rep. Tom MacArthur (R., N.J.) may even be ousted as the head of the centrist Tuesday Group for negotiating with the tea-party-aligned Freedom Caucus to revive the bill. "MacArthur has become so toxic within the group that he's intentionally stayed out of final negotiations this week, as leaders try to cajole dozens of centrists to accept the deal he brokered with conservatives," Politico's Rachael Bade and Kyle Cheney report. "My amendment has caused far more of a stir than I anticipated," he told them in an interview Wednesday. "And I made the judgment that I think for me, particularly with the moderates, it's better if I stay out of the way at the moment." MacArthur said one moderate colleague even told him, "You are going to make us lose the majority." Asked if he is worried about his leadership position, MacArthur responded, "We'll see."

9. No matter what happens, all this uncertainty about the future of the law is already taking a serious toll on the health system. "The insurance industry, which has long depended on stability, is trying to react to a highly uncertain political environment that shows no signs of stabilizing soon," Carolyn Johnson reports. "Amid arguments in Congress . . . insurers must make practical decisions in the next two months whether to sell plans in the marketplace next year. Billions of dollars in federal payments that help reduce deductibles and out-of-pocket costs have become a political football, with politicians refusing to commit to long-term promises about the payments. And the future of the marketplaces longer-term is hard to read amid the uncertain fate."

There has been a flurry of ominous developments in recent days that raise concerns about the coming collapse of the insurance marketplaces. Three examples:

Iowa's last major Affordable Care Act insurer threatened Wednesday to pull out from the state's marketplace next year.

"If Minnesota-based Medica follows through on its threat not to sell plans in 2018, Iowa could be the first state to lack any insurers on its exchanges in all but a handful of counties," Carolyn explains. "At the start of 2017, Iowa outwardly appeared to be an ACA success story, with three insurance companies selling competing plans on its exchanges broadly. But last month, two of Medica's competitors said they would exit the state's marketplace next year, citing financial losses. And on Wednesday, Medica released a statement saying its continued participation 'is in question.'"

Meanwhile, Aetna announced Wednesday that it will pull out of Virginia's individual marketplace next year, as it was on track to lose more than $200 million this year on insurance sales to individuals.

And Anthem chief executive Joseph Swedish said in an earnings call that his company, which has 1.1 million members in the exchanges, will consider exiting marketplaces — if there isn't a commitment to funding the federal payments that reduce out-of-pocket costs, called cost-sharing reductions.

10. Assuming the bill passes, it will immediately become the Senate's problem. One core argument being made to undecided House members is that voting for this bill gets the issue off their plate. You might recall that, in March, at least eight Senate Republicans said they had fundamental problems with the bill being considered. ABC News' Ali Rogin outlines the pockets of resistance in a new story:

Rand Paul, Mike Lee, and Ted Cruz all tweeted that they would oppose anything short of a full repeal of Obamacare. They also said the House bill's tax credit structure to help people pay for coverage amounted to a new entitlement.

Cory Gardner, Lisa Murkowski, Rob Portman and Shelley Moore Capito — from states that expanded Medicaid under the ACA — were concerned about the proposal's lack of protections for expansion beneficiaries.

Susan Collins opposes efforts to strip federal funding from Planned Parenthood.

Tom Cotton said the House bill did not do enough to address rising premiums and deductibles.

None of those objections even begin to take into account the rules of reconciliation, which mean that certain key provisions of the House bill are likely to be struck down by the parliamentarian.