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One tweet that explains Republicans’ big health care bill challenge

Sen. Rand Paul And Rep. Mark Sanford Discuss Their Efforts To Repeal The ACA Photo by Mark Wilson/Getty Images

The day after unveiling their new bill to replace Obamacare, the Republican authors of the Affordable Health Care Act find themselves in a bind.

Even if the new bill has the votes in the House, it will also have to pass the Senate. Because this legislation is moving forward through the budget reconciliation process, which only requires 51 votes, the 52 Republicans in the Senate can only afford two defections and still pass the bill (assuming Vice President Mike Pence would break a tie in their favor). A third defection would doom the Obamacare replacement package.

And, already, four Senate Republicans have already criticized Speaker Paul Ryan’s first proposal, saying it doesn’t do enough to protect Medicaid beneficiaries. That group consists of Rob Portman (R-OH), Sen. Shelley Moore Capito (R-WV), Sen. Cory Gardner (R-CO) and Sen. Lisa Murkowski (R-AK). Assuming Democrats stick together in opposition, that moderate bloc of Republicans could torpedo the bill on their own.

But appeasing moderates could carry risk for Republican leadership as well: Conservative senators could defect in protest of a bill they think is too far to the left. The most conservative senators are already blasting the first draft as not doing nearly enough to slow entitlement spending, with Sen. Ted Cruz (R-TX), Sen. Rand Paul (R-KY), and Sen. Mike Lee (R-UT) echoing the arch-conservatives in the House Freedom Caucus who say that the bill amounts to “Obamacare-lite” and leaves too much of Obama’s law intact, including the expansion to Medicaid in place until 2020 and the “Cadillac tax” on health care plans for those with high incomes.

National Review’s John Fund points out the difficult spot that Republican leadership is in on Twitter:

If anything, Fund’s tweet undersells the challenge leading Republicans face in building the coalition to get to the 51 votes they’ll need at a minimum to get Trumpcare through reconciliation.

It’s not just the fight over Medicaid. Sen. Bill Cassidy (R-LA), for instance, has said that the bill has to cover the same number of people as Obamacare. Sen. Bob Corker (R-TN) wants it to be neutral, meaning it doesn’t add to the deficit.

"I'm going to be very anxious to hear how we'll get to 51 votes and [how] the House gets to 218," said Sen. Roy Blunt (R-MO).

The Congressional Budget Office hasn’t yet estimated how many people the bill will cover or how much it will cost, key to Cassidy and Corker’s support. But the challenge is obvious from a mile away.

Meanwhile, Sen. Susan Collins (R-ME) and Sen. Murkowski say the House health bill should be stripped of its provisions to defund Planned Parenthood.

“If you go too far and have too many drastic cuts, you lose the moderate four,” says Josh Huder, a congressional scholar at the Government Affairs Institute at Georgetown University, citing Portman, Caputo, Gardner, and Murkowski. “And if you don’t go far enough, you lose the conservatives.” Republicans need both to get to 51 votes.

It’s perfectly possible either or both factions of Republicans are bluffing, simply hoping to pull the negotiations as far to their side as possible. “There's a high probability of that,” Huder says. That’s what happened during the debate over Obamacare.

In 2010, it looked like then-Majority Leader Harry Reid didn’t have the votes for the Affordable Care Act. Two versions of the bill were shot down after passing separate committees, Democrats like Joe Lieberman threatened to withhold support, and the future of health care reform seemed to be in danger.

Then the bill was reworked — and Reid had the votes. “All of a sudden, Harry Reid dropped a bill on the Senate floor that found the right mixture of people, and then the House swallowed the pill,” Huder says. “It looked like Obamacare was dead in the water — and then all of a sudden it sprang back to life.”

But even if some Republicans are bluffing because they hope to influence what the final bill looks like, the balancing act between conservatives and moderates is a real challenge.

“It’s going to be really, really hard for them to do this,” Huder says. “It’s the key question: Can they find a way to thread the needle here between the moderates and the conservatives in the Senate? There’s no way forward if not.”

Tara Golshan contributed reporting.