The final push on the health care bill started in earnest Monday night.

At 6 p.m., a cadre of Republican lawmakers from the Energy and Commerce Committee met in an unmarked Capitol office to make changes they hoped would bring moderate holdouts on board with the party’s overhaul of the health care system.

Michigan Rep. Fred Upton, the former Energy and Commerce chairman, was discussing what would get him to “yes” while preparing to email House Majority Leader Kevin McCarthy to alert him he would be a “no.” His opposition, which he announced the next morning, would reverberate through the conference because Upton, an ally of leadership, was known as a leader on health care policy.

But another change was already in the works Monday night. Upton huddled with his colleagues, including current Energy and Commerce Chairman Greg Walden of Oregon and Rep. Michael C. Burgess of Texas, the health subcommittee chairman, along with Reps. Joe L. Barton of Texas and Morgan Griffith of Virginia, two committee members who are part of the hard-line House Freedom Caucus. They spitballed broad policy changes that could appease Upton and other moderates, including a potential cap on premium increases for people with pre-existing conditions.

The idea was clarified Tuesday. Walden presented Upton a plan, at leadership’s urging: an extra $5 billion to reduce premiums and out-of-pocket health care costs for people with pre-existing conditions, who might see their premiums rise under the legislation. Upton pressed for more, and the group settled on an $8 billion fund over five years that would ultimately become the final amendment to the legislation.

With that deal in hand, leadership checked with the Freedom Caucus to ensure those members wouldn’t pull their support.

Leaders credit that amendment — which sought to tamp down widespread criticism from moderate members that the package didn’t do enough to protect people with medical conditions — with launching the momentum the GOP conference needed to secure the final votes.

The House on Thursday squeaked out a win by a 217-213 vote with the support of all but 20 Republicans, 15 of whom are members of the moderate Tuesday Group. No Democrats supported the bill.

The path to 217 was fraught. House Republicans missed every deadline they set out for themselves to deliver the repeal of the 2010 health care law, a campaign promise they had repeated for more than seven years. Leaders had to pull their first version of the legislation from floor consideration in March, when it became clear it lacked the support to pass.

Since then, various groups of Republicans have been huddling in meetings like the one convened Monday, to work out policy changes that have bought anywhere from one to 30 votes. In late March and early April, it was members of the Freedom Caucus who met in Rayburn hearing rooms into the wee hours, trying to find an acceptable change. After the April recess, New Jersey Rep. Tom MacArthur, co-chairman of the Tuesday Group, was leading the charge on his own proposal.

At the end, however, it came down to the small group of Energy and Commerce committee members, many of them frustrated by members without policy expertise proposing massive alterations to the measure.

“There was concern when people started changing things,” Burgess said, recalling panel members’ thoughts as: “Wait a minute, we spent 28 hours in markup. We worked on this thing pretty hard. In fact, we worked on it in 2015.”

Upton’s plan

Even after Upton huddled with Walden and his colleagues on his own policy change, he was unsatisfied. The details hadn’t been finalized and he was not sure a deal was forthcoming.

So Upton orchestrated a public declaration of his concerns. He told a local radio reporter early Tuesday morning he would vote “no” unless the bill changed substantially — a statement that set off a flurry of headlines, given Upton’s long record as an opponent of the health care law.

His opposition was “important,” Walden said after Upton announced it. “He’s a very thoughtful leader on health care and I think he represents a group of members of the conference that still have concerns about the opening of the language on pre-existing conditions.”

The attention gave Upton leverage and spurred a phone call with President Donald Trump at 4 p.m. Tuesday, which Upton said lasted for about 20 minutes. The president said then that he wasn’t open to any changes.

“We had a good give and take, truly,” Upton said. “I told him I couldn’t vote for it. He got a little angry, but I’ve got a thick skin.”

The president followed his call with Upton with one to Missouri Rep. Billy Long, a longtime ally who was an early supporter of Trump’s campaign. Long had come out Monday against the legislation because it didn’t do enough for people with pre-existing conditions.

Long, who had been briefed on Upton’s plan, suggested it to the president during their call, saying, “Why don’t you let me and Fred come over there to the White House?”

Trump declined, repeating his position that he did not want changes, Long recalled. He told the president, “All right, I’m still a ‘no.’”

Upton and Long’s declarations of opposition weren’t a surprise to House Majority Whip Steve Scalise.

“I knew last week that they were trending away from it,” the Louisiana Republican said Thursday. “So we had already built that in. But I also approached both of them and said we want to get you back.”

With the help of Scalise and House leadership, Upton and Long got a meeting with the president. Upton even offered to skip a dinner with National Institutes of Health Director Francis Collins on Tuesday night.

On Wednesday at 9:30 a.m., Upton and Long, along with Walden and Burgess, visited the Oval Office to brief the president. It took about 90 minutes, but they got Trump on board.

“Those four sold it — hard,” one person familiar with the negotiations said.

Final frenzy

Upton and Long then announced they would support the legislation, kicking off a day of frenzied Capitol Hill meetings aimed at holdouts.

Walden abruptly called a meeting of the Energy and Commerce Committee around 3 p.m. Wednesday to give the pair time to explain their change of heart to their colleagues. It took place just steps from a meeting room where Vice President Mike Pence, Health and Human Services Secretary Tom Price and other federal officials spent the afternoon lobbying other House Republicans.

Upton and Long, along with Griffith, Barton and others, cajoled colleagues on the House floor on Wednesday.

The last-minute whip effort, aided by Upton’s amendment, worked. Special promises from GOP leaders to lawmakers helped. Florida Rep. Daniel Webster, for example, secured a pledge that GOP leaders would eventually address Medicaid funding for his state’s nursing homes, after he met with Pence at the Capitol.

House leaders gathered in Ryan’s office just before 7 p.m. Wednesday night to confirm they were ready to call the vote. McCarthy and Scalise walked out less than half an hour later and told reporters confidently they had secured the “yes” votes needed.

On Thursday morning at 9 a.m., not a single member raised concerns at a GOP conference meeting, which had the tone of a pep rally, a GOP aide said.

Oklahoma Rep. Tom Cole said they blasted “inspirational music,” including songs such as “Eye of the Tiger” and “Takin’ Care of Business.” Ryan got a standing ovation when he stood to speak, said New York Rep. Chris Collins.

Despite the upbeat nature of the morning, GOP leaders held behind-the-scenes conversations to ensure the votes remained intact. Scalise said Pence called twice to check on individual members he had helped whip.

White House Chief of Staff Reince Priebus trekked to the Hill for meetings in Scalise’s office, where moderates were spotted heading in and out before the vote. When it came time to head to the floor, Scalise left his office with 20 to 30 members in tow. The group was heard cheering from inside before they left.

When the number of “yes” votes hit 216, Republicans clapped and cheered in celebration of the narrow victory.

Members rushed after the vote to board buses that transported them to the White House for their final celebration of the day. The members gathered around the presidential podium in the Rose Garden, where Trump, Pence and GOP leaders delivered remarks.

The line that seemed to draw the most cheers was this one from Pence: “Welcome to the beginning of the end of Obamacare!”