Trump’s hard sell sets up the highest of stakes for the House vote on Thursday: Defeat after such a direct plea would be a humiliating loss for the president, jeopardizing not only the GOP’s pledge to repeal the Affordable Care Act but other key elements of his domestic agenda as well. As Trump has lamented, his hopes for enacting a comprehensive tax-reform bill rest on the passage of healthcare legislation.

Republican leaders loved the president’s message, knowing that only he has the standing among the party base to threaten recalcitrant members who fear Trump’s bully pulpit. “The president just came here and knocked the ball out of the park,” Ryan gushed. “He knocked the cover off the ball.”

Yet the speaker, in a press conference after the meeting, also acknowledged how much he stands to lose if the bill goes down:

The president was very clear. He laid it on the lines for everybody. We made a promise. Now is the time to keep our promise. If we don’t keep our promise, it will be very hard to manage this.

One of the bill’s authors, Chairman Greg Walden of the House Energy and Commerce Committee, was more blunt: “This is a make-or-break vote. I’m not aware of any Plan B,” he told the radio host Hugh Hewitt.

Did Trump’s pitch work? Not with Meadows, who told reporters after the meeting that he still opposed the bill and that the leadership lacked the votes to pass it.

Nor did the changes Trump negotiated with Republican leaders appease a pair of key conservative activist groups. Moments after he left the Capitol, the Club for Growth announced it would buy $500,000 worth of ads in the districts of 10 swing Republicans to urge them to oppose “RyanCare.” Soon after, Heritage Action declared it would penalize Republicans who vote for the legislation on its annual scorecard. Industry groups representing hospitals, doctors, and many insurers remain opposed despite the changes, as does the AARP.

With Democratic support out of the question, Republican leaders can lose up to 21 votes on their side and still pass the AHCA with a bare majority of 216 votes. Unofficial whip lists have identified as many as 17 GOP lawmakers publicly opposed to the bill, with dozens more undecided. The leadership did flip several votes in the last few days. After changes to the legislation were announced, one group of four members announced their support. Other vote counts claimed there was already enough to defeat the bill without further changes.

In a sign that Trump was not as persuasive as he needed to be, conservative lawmakers began reiterating their opposition as Tuesday wore on. Representative Thomas Massie of Kentucky said he was still a ‘no’ vote, as did Representative Mark Sanford of South Carolina. Another member of the Freedom Caucus, Representative Rod Blum of Iowa, declared his opposition on Twitter and said the bill doesn’t do enough to lower premiums. “We’re rushing this thing,” Sanford said in a video posted by the conservative group FreedomWorks. He said conservatives were pushing the leadership to repeal the provisions of Obamacare listing the “essential health benefits” that insurance plans cover. Party leaders have said doing so would jeopardize the bill in the Senate, where budget reconciliation rules limit the changes Republican can make while passing a bill with fewer than a filibuster-proof 60 votes.