After weeks of secret deliberations, Senate Republicans are in the final stages of a sweeping rewrite of the nation's health care laws amid growing frustration among the rank and file over how to fulfill the party's top campaign promise over the past seven years.
Senate Majority Leader Mitch McConnell, R-Ky., said Tuesday that GOP leaders will produce a "discussion draft" on Thursday and hinted that a final vote could come next week - even as key senators expressed concern about the emerging legislation, the lack of transparency surrounding it and the disagreement that remains.
McConnell's desire to wrap up before the Fourth of July recess reflects the sense of urgency among Republicans, including President Donald Trump, to show progress on health care after years of vowing to "repeal and replace" the Affordable Care Act.
But McConnell's strategy for achieving that goal - writing a bill with a handful of aides behind closed doors - has come at a cost that reached new heights on Tuesday: anger among Republicans who feel shut out of the process.
"Do you know what the health care bill looks like?" Sen. Lisa Murkowski, R-Alaska, asked reporters Tuesday, her frustration evident. "Because I don't."
McConnell told reporters that he would "lay out a discussion draft Thursday morning; you'll be able to take a look at it" - but he declined to discuss the specifics. He said the Senate would take up the bill on the floor once it receives a score from the nonpartisan Congressional Budget Office - possibly Monday.
Trump has sent mixed signals to Capitol Hill and has played a more hands-off role in Senate deliberations than he did in the House. While the president has pushed for swift action on health care and celebrated the passage of the House bill in May, he also "wants a bill that has heart in it," press secretary Sean Spicer said at the White House on Tuesday. And at a private meeting with senators recently, Trump called the version that passed the House "mean."
Senate Republicans have vowed to repeal and replace key parts of the ACA, commonly known as Obamacare, the 2010 law that has provided insurance to about 20 million additional Americans through a combination of expanded Medicaid coverage and private insurance, much of which is federally subsidized.
But even among Republicans - no Democrats are expected to support the bill - competing ideological goals have complicated Senate negotiations. Among the challenges in a messy drafting process: how to lower insurance premium costs and eliminate what some view as burdensome coverage mandates without increasing the number of uninsured Americans. It has become both a political and a substantive question for some GOP senators - many of whom campaigned on a promise to "repeal and replace" but now face strong evidence that their constituents like their coverage and insurance protections under the ACA.
The more contentious issues have included how to slow spending growth in Medicaid and reducing requirements for health plans, such as mandated coverage for certain diseases or preexisting conditions.
Senate leaders hope to start debate by Tuesday or Wednesday of next week, said two senior GOP aides who spoke on the condition of anonymity to describe strategy - yet it remains unclear whether McConnell has the 50 votes he needs (plus the tiebreaking vote of Vice President Mike Pence) to pass the bill. Democrats and Republicans will each have 10 hours to debate the bill before being allowed to offer an unlimited number of relevant amendments in what is commonly known as a "vote-a-rama." If all goes as planned, a final vote could occur by the end of next week, the aides said.
Even lawmakers who have supported the idea of moving swiftly said they don't know what will be in the bill.
Sen. Bob Corker, R-Tenn., told reporters that while he and his colleagues "all understand what the tensions are" in reaching a compromise, it was impossible to say whether they had resolved them yet.
"Every single person is in the same place. They want to see the text," he said. "There's no way for anyone to know what we have until we have language."
Sen. Ted Cruz, R-Texas, a key architect of a health care working group that has been huddling regularly for weeks, said that while the senators "continue to make good progress" on crafting a compromise, "a great deal of work remains to be done."
The critical test, Cruz said, is whether the bill would drive down premium costs. "Right now, the current draft doesn't do nearly enough in that regard," he said.
As he left a working-group meeting Tuesday, Sen. Orrin Hatch, R-Utah, was asked whether Republicans had moved any closer to completing their work.
"Didn't seem like it to me," Hatch responded, with a chuckle. "There's still a lot of different points of view. And there are no simple answers to these problems."
One of the biggest and most divisive matters under discussion is how to structure Medicaid. Some GOP senators from states that expanded Medicaid under the ACA are trying to phase out higher federal payments at a slower rate than a bill that passed the GOP-controlled House in May. Some conservatives, meanwhile, are seeking to slow the growth of Medicaid's costs.
Sen. Patrick Toomey, R-Pa., called talks on the bill "a work in progress" on Tuesday. Toomey is leading the conservative Republicans who want to slow Medicaid's costs.
On the opposite end of the spectrum is Sen. Rob Portman, R-Ohio, who has been pushing for a seven-year phaseout of Medicaid expansion that he called a "glide path." McConnell has been pushing for a three-year phaseout. Both would be more gradual than the House bill.
Republicans hold a 52-48 advantage over Democrats and thus can afford to lose only two votes, even under the maneuver known as reconciliation they are using to enable them to pass it with a simple majority rather than the 60-vote majority required of most legislation.
Asked whether negotiations were far enough along to allow for a vote next week, Cruz, who is more concerned with paring back regulations in Obamacare than he is in the Medicaid debate, said, "I think our decision not to set artificial deadlines was the right decision."
Democrats have registered their displeasure this week with both the process and policy Republicans are spearheading. On Tuesday, they continued their protests, using a parliamentary tactic to slow other Senate business.
"If the Republicans continue down this path, ignoring the principles of transparency and the open debate that define this legislative body, we Democrats will continue to do everything we can to shine a light on what our Republican friends are doing," Senate Minority Leader Charles Schumer, D-N.Y., said on the Senate floor.
In 2009, two key Senate committees held extensive hearings and votes on bills that eventually formed the basis of the ACA. Two separate committees adopted dozens of GOP as well as Democratic amendments in meetings that lasted 13 days and eight days, respectively. The final Senate bill passed in December 2009, after 25 days of consideration on the floor. All told, the Senate considered the health care bill for a total of 160 hours.
Cruz dismissed the Democrats' criticism as unfounded.
"There has been no political issue in modern times more debated than Obamacare," he said, noting that controversy over the bill helped propel Republicans' electoral gains in 2010, 2014 and 2016. "The Democrats' complaint that we haven't talked enough is rich with irony."
The closed-door process has left many health care advocates at a loss. Dick Woodruff, senior vice president of federal advocacy for the American Cancer Society, said in an interview Tuesday, "We're doing what we can to communicate to the Hill what impact on coverage" the health care overhaul could have on its members.
Woodruff, who said his group was particularly concerned about potential cuts to Medicaid and the bill's impact on people with preexisting conditions, added: "The difficulty is that there isn't much coming back. It's like we're talking to a black box."
The Senate is scheduled to go into recess at the end of next week. If Republicans do not finish their work on health care before then, they may risk losing steam, as senators return to their home states and potentially face fresh resistance to their efforts.
Still, some Republicans said they were confused about the bill taking shape and warned against rushing.
"I'm hearing lots of conflicting information," said Sen. Susan Collins, R-Maine, a key centrist.
In a video he posted Tuesday afternoon on Facebook, Sen. Mike Lee, R-Utah, said he had not seen the bill, despite being a part of the Senate GOP health care working group.
"I'd be fine, don't get me wrong, to be voting on something soon," Lee said. "But we should be able to see it first."