Senate Majority Leader Mitch McConnell is known for his dealmaking and ability to deliver a bill over the objections of some of his members.

On healthcare, McConnell's had his work cut out for him: The House bill to replace the Affordable Care Act was widely panned by Republican senators and the public, he could afford to lose only two votes on the Senate's version of the bill, and he had to get it passed with a relatively short window.

Given those pressures, it's no surprise that the Senate GOP's bill, called Better Care Reconciliation Act (BCRA), is on its third iteration and still facing an uphill battle to pass.

Despite the tough road ahead, strategists say that McConnell's penchant for cutting deals may be enough to save the BCRA.

Start moderate

Since the start of deliberations on the Senate, leaders have promised to craft a more moderate bill than the House's American Health Care Act.

Given the parts of Obamacare that the BCRA kept — including its tax credit structure, slower phase out of Medicaid expansion, and funding to offset insurer costs — conservative groups took issue with the bill as too far to the center.

A former Senate GOP leadership aide told Business Insider that it was clear that McConnell was trying to ensure moderates were on board from the start.

"I think there is a very credible case to be made that this bill was center right to begin with and is still a center right bill," the former aide said.

Despite this, many moderate members are still cold on the bill due to the fact that it'll cut $772 billion cut out of the Medicaid budget through 2026.

This was identified as the biggest issue by a large number of moderates after the release of the first version of the BCRA and remains the largest complaint with the newest version.



Kickbacks

There are some kickbacks for individual members. For instance, there are provisions in the bill that would shift a bit more of the funding to Alaska to please Sen. Lisa Murkowski. And there are some adjustments to how Medicaid funding is allotted in a public health crisis to shore up Marco Rubio's vote after he expressed some concerns.

Whether or not those will be enough to win over the needed votes remains to be seen. Since the bill is going through the budget reconciliation process, McConnell only needs to get a simple majority to pass the bill. Given the make-up of the Senate and the total opposition by Democrats, this means it'll take only 3 GOP defectors for the BCRA to fail.

Sen. Susan Collins of Maine immediately jumped out against the bill, saying that it did not address her concerns and she would vote against a key procedural vote, called a motion to proceed.

Other moderates like Rob Portman of Ohio, Dean Heller of Nevada, Shelley Moore Capito of West Virginia, and Alaska's Murkowski would not commit either way on a motion to proceed.

A Portman aide told Business Insider on Thursday that the senator "will review the text of the new bill and CBO analysis before making any decisions on this new version."

The best tactic in McConnell's arsenal may simply be to pressure the remaining hold outs on this side. Perhaps the best summation of the McConnell strategy with this side comes from a GOP aide who told Axios' Caitlin Owns a few weeks ago simply: "Moderates always cave."

Conservative concerns

Given the relative starting point of the bill compared to the House version, conservatives immediately took issue with the BCRA.

Sen. Ted Cruz of Texas, Rand Paul of Kentucky, Mike Lee of Utah, and Ron Johnson of Wisconsin immediately came out against the bill because it kept intact too much of Obamacare's regulatory structure and taxes.

This necessitated a concession to this group by McConnell, which came in the form of a consumer freedom amendment from Cruz. Under the new BCRA, insurers can offer plans that do not comply with two major Obamacare regulations, which experts worry could undermine protections for people with preexisting conditions.

Due to some differences between the plan presented by Cruz and Lee and the final product on rolling back the regulations (along with the preservation of the Obamacare taxes), the right wing of the party still hasn't been won over. Paul said he will not vote for the procedural vote to bring the bill to the floor. Cruz and Lee have not committed either way

"We do not like it," a Lee aide said of including of the Obamacare taxes. "There is a lot about the bill we do not like."

Still not enough

Even after tweaking the bill and trying to goose individual members, McConnell is still facing a simple math problem.

With Paul and Collins firmly against the motion to proceed, McConnell can only lose a single vote to even bring the BCRA to the floor for debate. Senators don't like to be the one person that killed a bill, but as of now even bringing the bill to the floor is not a slam dunk.

According to a Republican strategist familiar with leadership, however, the thin margin does not mean McConnell should be counted out.

"Nobody knows the Senate Republican conference better than McConnell, whose unique understanding of what each member wants is unparalleled in recent history," the strategist told Business Insider.

McConnell's track record and the funding available to him to shore up the support of members should be enough to get the bill across the finish line, said Rick Weissenstein at Cowen Washington Research Group,

"We continue to believe the Senate will narrowly pass a bill before the August break based on McConnell's prowess at cutting deals and the additional $230 billion in funds available to make changes to the bill to win over recalcitrant members," he said.