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It's going to be tough to satisfy all of the Republicans who have problems with the House Obamacare replacement bill — conservatives who want a faster end to Medicaid expansion, Republicans from states that want to keep their Medicaid expansion, and especially moderates who are rattled by the massive health coverage losses predicted by the Congressional Budget Office.

But don't assume that's the end of the road. Smart Republicans who were around for the passage of Obamacare, the mirror image of what Republicans are going through now, tell me there's probably still a path to President Trump's desk for something they can call repeal. Just don't assume it's going to look like this bill.

The realities:

  • Republicans can't just give up on repeal after running on it in four elections. The CBO report "certainly does have a discouraging impact, but the reality is, failure is not an option," said Chris Condeluci, a former Senate Republican aide who worked on the Affordable Care Act and a member of the Axios board of experts.
  • Some Senate Republicans are criticizing the bill now and want changes, but there's no way for the Senate GOP to come up with a strategy without knowing what the final House bill will look like — since it could be changed in the Rules Committee next week before it goes to the floor, according to a Senate GOP leadership aide.
  • Senate Majority Leader Mitch McConnell is more likely to offer moderate Republicans some changes — like modifying the tax credits to boost coverage and softening the Medicaid cuts — than to pull the plug, Condeluci said.
  • But the rules are strict on what kinds of changes would be allowed under the budget "reconciliation" procedures, and if the bill changes too much, Republicans will lose the protections that allow them to pass the bill with 51 votes.
  • A bigger problem is that Trump's allies are starting to see the current bill as "deeply flawed — and, at worst, a political trap," per the Washington Post.
  • The waiting game right now is to see whether any Republicans will declare the House bill a non-starter in the Senate.
  • Rodney Whitlock, a former Senate Republican aide, notes that when Democrats passed the Affordable Care Act, it took Joe Lieberman to kill off the "public option" — which everyone knew couldn't pass the Senate anyway. Now, with the House GOP bill, "no one wants to step forward and say, 'I'm not comfortable with these numbers and I'm not voting for it,'" said Whitlock.
  • If someone does, that probably ends the exercise of trying to pass House Speaker Paul Ryan's bill. But it opens an opportunity for a more moderate Republican, like Sen. Lamar Alexander, to work with Democrats on something closer to a "repair" bill — which Alexander says he's wanted to do all along.

The bottom line: Republicans have to press forward with the current bill and drive it as far as they can. But there could be a pretty big pivot point in the Senate — and the final version of Trumpcare could look very different from this version.

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