President Trump, the author of “The Art of the Deal,” has been projecting his usual bravado in public this week about the prospects of repealing the Affordable Care Act. Privately he is grappling with rare bouts of self-doubt.
Mr. Trump has told four people close to him that he regrets going along with Speaker Paul D. Ryan’s plan to push a health care overhaul before unveiling a tax cut proposal more politically palatable to Republicans.
He said ruefully this week that he should have done tax reform first when it became clear that the quick-hit health care victory he had hoped for was not going to materialize on Thursday, the seventh anniversary of the act’s passage, when the legislation was scheduled for a vote.
Two of his most influential advisers — Stephen K. Bannon, his chief strategist, and Gary D. Cohn, the National Economic Council director, who had a major role in pushing the bill — came to agree, and did not like the compromise that was emerging. So on Thursday night, Mr. Trump delivered an ultimatum.
He dispatched his budget adviser, Mick Mulvaney, to a conference of House Republicans and told them they had to vote on Friday. And if the bill fails, he said, Mr. Trump will move on.
A president who prefers unilateral executive action and takes intense pride in his ability to cut deals finds himself in a humbling negotiation unlike any other in his career, pinned between moderates who believe the health care measure is too harsh, and a larger group of fiscal conservatives adept at using their leverage to scuttle big deals cut by other Republican leaders.
Over the years, Mr. Trump has proved to be a resilient operator, and even his most scathing critics do not rule out his ability to pull off some kind of a deal, even at a late hour.
“I don’t know whether he will ultimately succeed or fail, but I will tell you that President Trump is so transactional, who knows what transactions he will be willing to make to pass this,” said Representative Nancy Pelosi, the Democratic leader, who passed the Affordable Care Act in 2010 as speaker.
“So far he’s acting like a rookie. It’s really been amateur hour,” she added. “He seems to think that a charm offensive or a threat will work — that saying ‘I can do this for you’ or ‘I can do this against you’ will work. That’s not the way it works. You have to build real consensus, and you have a to gain a real knowledge of the policy — and the president hasn’t done either of those things.”
Crashing on the shoals of Congress marks Mr. Trump’s first true encounter with legislative realities and the realization that a president’s power is less limitless than it appears, particularly in the face of an intransigent voting bloc. Mr. Trump is not used to a hard no — but that was the word of the week.
Before he sent Mr. Mulvaney to Capitol Hill to deliver his message Thursday night, the president had met with recalcitrant lawmakers at the White House. Mr. Trump reiterated his veiled threat that Republicans who voted no would be punished by constituents who demand they fulfill their promises to roll back the law. He made clear to members of the House Freedom Caucus during a testy hourlong face-off in the Cabinet Room that they were going to have only have one chance to fulfill their vows of repealing and replacing the health law, and this was it, according to people who were in the room.
If Mr. Trump has any advantage in the negotiations, it is his ideological flexibility: He is more interested in a win, or avoiding a loss, than any of the arcane policy specifics of the complicated measure, according to a dozen aides and allies interviewed over the past week who described his mood as impatient and jittery. Already, he has shown that flexibility by going back on campaign promises that no one would lose coverage when the Affordable Care Acrt was replaced and he wouldn’t cut Medicaid.
To Mr. Trump and his team, the health care repeal is a troublesome stepchild. His son-in-law and senior adviser, Jared Kushner, who is vacationing with his family in Aspen this week, has said for days that the bill was a mistake to support. Yet Mr. Trump wants to fulfill his party’s pledge to roll back President Obama’s signature accomplishment, but only as a prelude to building his wall, cutting taxes and pushing his $1 trillion infrastructure package.
But resistance from his own party forced Mr. Ryan to delay the vote — even if he cast it as a take-it-or-leave-it deal.
Until this week, Mr. Trump was slow to recognize the high stakes of the fight, or the implications of losing. He approved the agenda putting health care first late last year, almost in passing, in meetings with Mr. Ryan, Vice President Mike Pence and Reince Priebus, the White House chief of staff.
Staff members agreed on a hasty rollout strategy during weekend meetings earlier this month — with Mr. Pence suggesting that the president maintain distance from the proposal, urging him to refer to the bill as Mr. Ryan’s creation, according to senior Republicans.
Only in the past two weeks, as Mr. Trump focused on his ongoing defense of accusations that his presidential campaign colluded with Russia, has he focused his energies and powers of persuasion on ramming through a proposal that is likely to result in the loss of health insurance for millions, according to Congressional Budget Office estimates.
On Wednesday, Mr. Trump made a key concession to fiscal hawks by agreeing to scrap the health care law’s provision mandating “essential benefits” — like outpatient visits, mental health services and some maternity care — in a bid to lower premiums. But that was not enough. Representative Mark Meadows, the North Carolina Republican who leads the Freedom Caucus, said he was still a no.
That concession also risked alienating center-right Republicans in the House and Senate, where the bill already faced an uncertain fate.
“In order to get this bill out of the House, they have pushed this bill too far to the right,” said Representative Charlie Dent, a moderate Pennsylvania Republican who planned to vote against the legislation, and who was singled out for pressure by Mr. Trump at a meeting on Thursday. “It’s a mistake. Even if it passes, the Senate will never accept it.”
David Winston, a pollster who works with the House Republican leadership, said any delay could block Mr. Trump’s entire agenda. “You’re not looking at health care in isolation; you’re looking at an agenda that they want to pursue, and obviously the next big one coming up is going to be tax reform,” he said. “Whichever came first was going to set up the other.”
But Thursday’s reality check came with a Trumpian dose of the surreal.
Mr. Trump appeared almost oblivious to the dire situation unfolding in the hours after he hosted a meeting with members of the House Freedom Caucus at the White House, where he made the case Mr. Winston pointed to — that not passing the health bill risks the rest of the Republican agenda.
In the midafternoon, a beaming Mr. Trump climbed into the rig of a black tractor-trailer, which had been driven to the White House for an event with trucking industry executives, honking the horn and posing for a series of tough-guy photos — one with his fists held aloft, another staring straight ahead, hands gripping the large wheel, his face compressed into an excited scream.
At a meeting inside shortly after, Mr. Trump announced that he was pressed for time and needed to go make calls for more votes.
A reporter informed him that the vote had already been called off.
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