That title is not a weak attempt to make a pun on the genetics company "23andMe." It is not a throwback to "23-skidoo." And it's definitely not an attempt to sound like a quarterback calling signals at the line (besides, it's the wrong season for football metaphors). Instead, it represents the three biggest hurdles that Republicans now face in their efforts to dismantle Obamacare.
The first two are actual numbers, unlike (for the moment) the last one. Twenty-two is the number of votes Republicans cannot afford to lose in the House. Likewise, if they lose only three senators, the bill will also fail. So far, Paul Ryan should be worried about both of those numbers. But the biggest headache is going to arrive for Ryan next Monday, when the Congressional Budget Office is slated to release its "score" of the GOP health bill. Because the C.B.O. numbers might just push both the House and the Senate Republicans into open revolt over what was supposed to be their party's signature issue.
It should be noted that some Republicans are already revolting. OK, I freely admit that that previous sentence was just too tempting to pass up, because it really should be followed by a rimshot (ba-dum-DUM). But putting aside cheap humor, Ryan may already be in trouble within his own house's Republican caucus. He was able to shove the measure through two committees in the middle of the night, but few Tea Partiers were on those committees to gum up the works. He faces a much bigger challenge when the bill gets to the floor.
As I wrote earlier this week, Ryan's bill (dubbed "Ryancare" by waggish Republicans opposed to it) is already being attacked from both the center and the far right -- and that's within the Republican Party alone. This standoff is between those who think Ryancare is too Draconian, and those who think it is not Draconian enough. Powerful conservative groups are lining up on the "not Draconian enough" side, although a few establishment Republican groups (such as the Chamber of Commerce) are supporting it. Virtually everyone with an interest in the entire health care industry -- doctors, hospitals, insurance companies, seniors' groups, etc. -- have lined up against the bill. Democrats seem pretty united against it as well, but that should have been expected.
The problem is that any bill acceptable to either the Tea Partiers or the moderates likely couldn't pass both houses of Congress. It's hard to imagine any sort of compromise being reached by these two groups, since any movement towards one of them is necessarily a movement away from the other. They're playing a zero-sum game, in other words. One wins, the other loses. There is one interesting dynamic which may come into play, which is the relative strength of both groups in the two houses. In the House, the Tea Party may be stronger (and more unified) than the moderates. The "House Freedom Caucus" (as they're calling themselves these days) has enough votes to sink any bill Republicans are trying to pass without Democratic support -- far more than the 22 which are necessary. The moderates are not as well organized in the House, and might be convinced to vote for anything just so they can go back and campaign on "I voted to kill Obamacare." So the Tea Party could force Ryan into drastic changes in the bill as the only path to getting it passed.
The Senate, however, is another story. With such a small margin, any three Republicans can band together to stop the bill in its tracks. And there are already two distinct groups which seem to have met this bar. At least three hardliners (led by Rand Paul) have already strongly come out against the bill because it gives any assistance to poor people to buy health insurance. Which means nothing short of cutting off all tax credits and other subsidies is going to change their minds about the bill. But the opposition (again, just within the Republican caucus) seems even stronger, as the number of Republican senators coming out against the bill because it slashes Medicaid so much continues to rise (I should mention that the Washington Post put up a "whip count" of skeptical Republicans, if you're interested to see the individual names and what they've been saying so far).
The relative strength of the hotheads and the centrists is part of the American system, of course. You can win re-election in a rabidly Republican House district by taking the position that Ryancare doesn't go far enough, in other words, but senators have to appeal to a broader audience and they also have to deal with governors who will feel the pinch if the Medicaid expansion funds are cut off.
Where does this leave Paul Ryan? Well, it's really too early to tell. This early in the legislative process, a lot of people say a lot of things only to walk them back later. Strong opposition can sometimes turn into grudging acceptance, with a few tweaks to the bill. The White House is mounting a full-court press on the issue, trying to sway Tea Partiers to support Ryancare. Trump himself is not only issuing stark warnings of what will happen to Republicans in the 2018 midterms if they don't pass Ryan's bill (notably using the term "a bloodbath"), but he's also personally threatening to hold rallies in recalcitrant Republicans' home districts, to whip up the voters and provide more pressure to fall in line. This, if it happens, will be an interesting experiment into what Republican voters really believe. If the Tea Party is calling the bill "Obamacare-Lite" and refusing to support it, can Trump change these voters' minds? That's unknown, at this point, but it certainly will be interesting to see, one way or another.
Donald Trump -- very obviously -- doesn't really care exactly what is in the bill. He cares (as he always does) more about the optics. As long as a Republican Congress can pass something they can reasonably label "repeal and replace" and put it on his desk, Trump will sign just about anything, without batting an eye. Trump also knows that if Ryancare fails to pass, it will be an enormous black eye not only for him but for the whole Republican Party. They will have failed to achieve the biggest promise they made to their voters, right out of the gate. If the whole effort falls apart, Republicans are going to be seen as a party which cannot govern even when given the House, the Senate, and the White House. That's going to be brutal, politically.
Can Paul Ryan get enough of his own Republicans on board to even get his bill passed by the House? That's a real question, at this point. If he manages this feat somehow, he's going to have even more problems over in the Senate. If the Senate refuses to pass the House bill, and perhaps passes a bill of its own, the two versions will have to be reconciled -- and Tea Partiers hate compromising on anything (even with their fellow Republicans).
The math required to beat the numbers 23 and 3, however, may get a lot worse come Monday. Ryancare is almost guaranteed to leave millions (perhaps more than 10 million) without the health insurance they finally gained under Obamacare. It's designed that way, after all. But the C.B.O. report also may have some other shocking numbers contained within it. The two biggest of these will be what Ryancare does to the deficit and national debt, and how Ryancare changes the strength of the Medicaid system. Because Ryan is insistent on handing out enormous tax breaks to the wealthiest Americans in his bill, Ryancare could wind up actually costing more than Obamacare -- even though it will cover far fewer people. If Ryancare adds a big chunk to yearly deficits over the next 10 years, even more Republicans may revolt. Fiscal hawks will be outraged -- at least, those fiscal hawks that honestly believe in fiscal hawkery, as opposed to those who just use it as an occasional handy political bludgeon to use against Democrats. And if the Medicaid system is projected to have financial problems years earlier than under Obamacare, it may cause even more Republicans to balk. This is one of Obamacare's underappreciated benefits -- since passed, the projections have gotten a lot better than they used to be.
Those are just the most-predictable numbers from the upcoming C.B.O. report. There may be other surprises as well, in unexpected places. But overall, if the C.B.O. predicts that Ryancare will be more expensive, cover far fewer people, and have a much worse outcome for millions of people, it's going to be a hard enough sell for Ryan and Trump. So far, that's what everyone is expecting from the C.B.O., so it won't come as any surprise to those paying attention.
Politically, this may be an impossible lift. Let's see... more expensive... millions lose their coverage... and a worse outcome... yeah, that'll play in Peoria. "We want to spend more money for less!" is hardly a traditional Republican talking point, after all. In fact, both sides of the Republican debate may find numbers in the C.B.O. report to strengthen their anti-Ryancare position. This is the main reason why Republicans have talked a lot about replacing Obamacare but until this week have never brought a bill to the floor of either chamber of Congress. They've been afraid of the C.B.O. numbers all along, and for good reason. Speaking in vague generalities about how wonderful the GOP replacement plan will be works great when campaigning to a conservative crowd, but to actually pass any bill requires a score from the C.B.O. And those numbers are pretty much guaranteed to disprove many (if not all) of the claims the Republican politicians have had lots of fun making for the past seven years.
No wonder Paul Ryan is trying to hustle the bill through the House before anyone can figure out what's in it. Just like Republicans falsely accused the Democrats of doing. Next Monday, America will get to see the real GOP healthcare numbers for the first time. If those numbers add up to 22 House Republicans or three GOP senators against the bill, then Paul Ryan is going to have to head back to the drawing board.
Trump's right. This health care reform stuff is a lot harder than it looks.
-- Chris Weigant
Follow Chris on Twitter: @ChrisWeigant