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Reporters from Bloomberg, Politico are rushing around and interviewing countless unnamed sources to tell the same story they’ve been telling for months.

Whether Republicans can pass the big new GOP Affordable Care Act change bill, the Graham-Cassidy-Heller-Johnson bill, in time to affect 2018 will depend on whether the most conservative Republicans in Congress, and the most moderate Republicans in Congress, can close their eyes, hold their noses and control their stomachs long enough to vote for the same bill.

Sen. Lindsey Graham, R-S.C., has said that Senate Majority Leader Mitch McConnell supports the bill, which would keep the Affordable Care Act exchange system in place; keep current ACA subsidies in place during a transition period; eliminate some ACA taxes but keep others; eliminate the ACA individual and employer mandates; keep many ACA programs and commercial insurance rules in place; and replace the current ACA individual and insurer subsidy programs with new block grants and ACA rule waiver programs for states. 

(Related: 10 Medicare for All and Graham-Cassidy Highlights, for Agents)

Democrats say the bill would let states gut the ACA rules that now protect people with health problems against having to pay higher prices than other people for lower-quality coverage.

McConnell is willing to bring the bill to Senate floor if he thinks he has 50 votes, according to press reports.

For a look at the obstacles between the bill and President Donald Trump’s desk, and why Graham and his colleagues might, possibly have a shot at overcoming those obstacles this time around, read on.

Sen. John McCain, R-Ariz. (Photo: McCain)

Sen. John McCain, R-Ariz. (Photo: McCain)

1. John McCain

Democrats in the House and Senate appear to be united in opposition to the Graham-Cassidy bill.

That means Graham-Cassidy supporters must win the support of at least 50 of the 52 Republicans in the Senate to get the bill through the Senate with a majority vote.

Back in July, when the Senate considered several Republican Affordable Care Act change bills, supporters were able to attract just 43 Republican Senate votes for a long change bill, and just 45 votes for a shorter bills.

When the final proposal in that series of bills, the very shortest bill, came up for a vote July 28, two of the most moderate Republican senators, Susan Collins of Maine and Lisa Murkowski of Alaska, voted against it.

Sen. John McCain, R-Ariz., who has sided with the Republican majority on most votes, joined with Collins and Murkowski to kill the skinniest ACA change bill.

At press time, Collins, Murkowski and McCain were still holding back from supporting Graham-Cassidy.

Some of the other Republican senators who voted for the skinniest bill considered in July, but not for some of the longer bills, were also holding back from saying how they would vote.

On the other hand: those Senate moderates could relent, if they believe passing the bill is the only way to get the subsidy money to keep the individual major medical market breathing in 2018.

Sen. Rand Paul, R-Ky. (Photo: Paul)

Sen. Rand Paul, R-Ky. (Photo: Paul)

2. Rand Paul

Many would-be Affordable Care Act changers have also come up against opposition from lawmakers on the right, in part because few of the Republican ACA change bills that have gotten much attention would actually repeal much of the ACA, or even de-fund much of the ACA.

House members, for example, recently passed H.R. 3354, a federal spending bill for 2018 that would block any federal spending implementing or enforcing on most ACA rules or programs. Most observers say the final spending bill is likely to be much different from the version of H.R. 3354 that the House approved.

Graham-Cassidy would leave many parts of the ACA, including the ACA net investment tax and the ACA Medicare surtax, in place. It would also leave many ACA mandates, such as the ACA Summary of Benefits and Coverage notice requirement, in place.

Sen. Rand Paul, R-Ky., has already said he will oppose the Graham-Cassidy bill because it leaves too much of the ACA in place.

Graham-Cassidy “keeps Obamacare and tells the states to run it,” Paul tweeted today. “No thanks.”

On Friday, Paul tweeted, “Why continue putting out bills breaking our promise to repeal?”

If Paul sticks to opposing Graham-Cassidy, then supporters of the bill can afford to lose only one moderate.

On the other hand, it’s still possible that someone like Paul could relent on the floor if he finds he’s the only vote standing between the success and failure of an ACA change bill. Paul is an eye doctor, and his state includes Louisville. Louisville is the headquarters city for Humana Inc. and ,

House Speaker Paul Ryan (Photo: Ryan)

House Speaker Paul Ryan (Photo: Ryan)

3. House Tea Party Members

Many observers have suggested that the most conservative House members, including those who ended up supporting H.R. 1628, the House Republican ACA change bill, only at the last minute, are likely to be as cold at the Graham-Cassidy bill as Rand Paul.

House Speaker Paul Ryan had struggle in May to push H.R. 1628 through the House.

But Sen. Bill Cassidy, R-La., who has been working on the Graham-Cassidy proposal for more than a year, has lined up statements of support from the Christian Coalition of America and the Family Research Council.

Some publications reported that another conservative Republican group, the Tea Party Patriots opposed the Graham-Cassidy bill, but the group put out a statement saying it supports the bill and sees it as a “step toward full repeal of ObamaCare.”

The idea that continuing to oppose Graham-Cassidy could keep the current version of the Affordable Care Act intact until mid-2017 could lead some other critics of ACA change bills to accept the idea that blocking some parts of the law is better than leaving the entire law in effect.

— Read Kaiser Chief to Congress: You Have Just Days to Save Individual Health on ThinkAdvisor.

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