Senate health care state of play: 'Hanging by a thread'

Tuesday is another critical day for the Senate health care bill as Majority Leader Mitch McConnell and Vice President Mike Pence have a power lunch of sorts with their fellow Republicans to determine the way forward.

Here's the state of play as of Tuesday morning.

Where we stand

"We're hanging by a thread right now," one GOP aide told CNN Monday night.

Why we're here

It wasn't a surprise that the topline coverage number in the Congressional Budget Office report Monday was bad. Republicans thought it would be better than 22 million more people becoming uninsured by 2026 years than under Obamacare, but they knew it would be a bad headline. The surprising turn has been the reaction of their members, who have shied away from the bill.

RELATED: Senate health care whip count

What to watch Tuesday

The Senate GOP all-senators lunch is very, very important.

This will the opportunity for McConnell to take the temperature of his whole conference. Pence will be there, too. This kind of meeting determines next steps -- can they find a path forward this week? Do they pull it and negotiate over the recess? Do they put it up and let it fail? Today should provide clarity.

Also of note: Pence meets with conservative senators in the evening -- several of whom are struggling with this bill.

Why the "motion to proceed" matters

Procedurally, you can't get to the actual bill or any of the amendments, if you can't get through the motion to proceed, that's obviously not a positive sign.

But far more important is that traditionally members of the majority, even those who plan to oppose something, will vote to proceed to the bill. It keeps the process moving, it allows them to continue to work toward changes or amendments. It serves as a nod to leadership that you'll at least be a good soldier on the procedural things.

That blew up Monday night -- and caught GOP leadership off guard, according to multiple aides. There was a real possibility that the procedurally vote would've taken place this evening or Wednesday at the latest. Not anymore.

In other words, after weeks of people having "concerns" or "problems" with the process or drafts, Monday night was the first senators actually did something. They dug their heels in. And they created a major problem for leadership, who can only lose two Republicans on these votes.

Who is on record against the procedural motion?

*Ron Johnson

*Susan Collins

*Dean Heller

*Rand Paul

Who hasn't declared but may be near that place?

*Lisa Murkowski

*Mike Lee

Senate GOP aide on the above names

"I'd say you guys are undercounting those with major concerns right now."

Is this thing dead?

No.

Big pieces of legislation die a thousand declared deaths before they magically find a way to passage. Deadlines -- and near death experiences -- sharpen the senses. But as of this moment, it's in a bad place.

How could it die?

If this thing is going to die, having it die on a procedural motion, rather than after a 10 hour vote-a-rama, packed with terrible political votes, is probably the best case scenario for Republicans.

Do they still want to vote this week

Yes. And the threat still stands that it's this week or bust. There's a lot of skepticism that McConnell means that - what's the problem with pulling it back and giving members another 10 days to work through this? There's posturing on all sides here, but senior GOP aides insist the threat is real.

What's the pitch to still vote this week

Three-fold:

1. First and foremost, you campaigned on this for 7 years. This is why a lot of you are here. Voters will punish you more for failure than passage.

2. This isn't going to get better with time. The conference dynamics are well known. A week of recess, packed with protests, isn't going to make those dynamics any easier to navigate.

3. We need to move on. There's a packed agenda of must-pass items. The conference can't afford to keep dithering on this.

What needs to happen

Leaders need to move very quickly on changing the bill to appease their members. That's been happening behind the scenes since Friday - draft changes trading back and forth between staff. McConnell talking to his members and trying the thread the needle. The thought was that they had more time to work these things out - that their members would vote for the motion to proceed to get to the bill before things were finalized, then they'd have another couple of days to hammer out final deals. That no longer exists.

What's this about $200 billion to get votes?

The glimmer of good news in the CBO report is the deficit reduction number. $321 billion gives GOP leaders around $200 billion to play with (remember - the Senate has to at a minimum match the House savings in order to comply with budget rules. That House number has been calculated at at $133 billion.) So now McConnell has around $200 billion to go wrangle members -- more money for opioids, softer landing for Medicaid expansion, more targeted rural hospital funding -- and if members want to get to yes, they now can. That's a big deal.

But what about conservatives?

Adding new money to the bill doesn't help their concerns at all -- may actually push them further away. Conservatives like Cruz and Lee have very specific requests, particularly related to creating the option for entirely non-Obamacare regulatory compliant insurance plans. They also want more money and state flexibility for health savings accounts.

That's a big ask, but one they aren't backing off of. McConnell needs to find a way to try and address this, while not losing moderates terrified of the proposition of allowing anything in that would be perceived as cutting back regulations tied to pre-existing conditions.

RELATED: Who gets hurt and who gets helped by the Senate health care bill

Possible way to thread the needle

The open amendment process. Should they make it to actual consideration of the health care bill, the budget rules require an open amendment process. Republican leaders for weeks have privately told their conference they want to tightly control that process - and largely restrict amendments from their own members in order to not throw off any careful policy balance that exists.

Senators have always had to opportunity to offer whatever they see fit, but they hope was that they'd largely stay in line.

That may change now -- giving members the opportunity to propose amendments to whatever they see fit. This is a very, very risky proposition, even for someone who understands/manages the floor as well as McConnell.

Democrats will identify any poison pills and provide 48 votes for them immediately. But promising amendment votes on any sorts of GOP member priorities may be the best way to at least try and get members to vote to move forward at this point, even if it's not enough to secure final support.

Quick political addendum

People close to McConnell are very unhappy about the Trump super PAC targeting (or threatening to target) GOP senators like Nevada's Dean Heller over health care.

"Doesn't help. Probably hurt. Seems pointless," a source close to GOP leadership said. The concern is that it actually has the opposite effect -- hardening opposition to the bill that already exists. "The conference needs space to get to 'yes' this week," the source said. "This is the opposite of that."