It has become a well-worn meme that the Republican healthcare reform bill is in big trouble.  Without trying to sound like a politician, that is both true and false.

It is true because both conservatives and moderates within the GOP have objected – some of them loudly and publicly – to major provisions of the bill.  The moderates believe it goes too far in reducing the number of insured.  Conservatives believe it goes not nearly far enough in reducing government control and calls it Obamacare lite.  And both ideological camps must be sufficiently assuaged for the bill to become law.  This is especially true in the Senate, where the GOP holds 52 seats, a thin majority which must be held together.  Democrats, none of whom are likely to vote for the bill in any form, have become irrelevant to the process, just as Republicans were during Obamacare.

But it is also false to say this legislation is in trouble because of the final shape of the bill – sure to be hammered out at great length by the House and then the Senate and then in conference between the two houses of Congress – is far from determined.  And we have a president who is the “art of the deal” master negotiator, who fully understands the importance of closing the deal on this first, vital legislative effort, and who has famously presented himself as a winner (you’ll get so sick of winning, you’ll say please, Mr. President, we can’t take any more of this winning…).

Especially given the fragile state of his new administration due to unrelenting opposition from the left and all the establishment media attention focused on his “relationship” with Russia and his failure to produce evidence that he was “wiretapped” by Barack Obama, it is almost inconceivable that Donald Trump would accept defeat on this healthcare bill.  It would sour and threaten the credibility of his entire presidency going forward.

On Monday, the GOP announced a first round of revisions to the bill designed to answer some – but certainly not all – of the objections of both wings of the party. For the moderates, there is an additional eighty-five billion dollars in tax credits for older and sicker Americans.  The rest of the amendments are concessions to conservatives: termination of Obamacare taxes this year – one year earlier than scheduled in the original bill, work requirements for able-bodied Medicaid recipients, and the option for states to choose between Medicaid block grants (giving the states more control) or a (likely more generous) per-capita payment from the federal government.

Rest assured that this is only the initial round of amendments.  Many more are likely to follow.  And yet more will come outside the confines of this legislation, including a major talking point for the president in his rally in Louisville Monday night: competitive bidding on pharmaceuticals.  It starts at 36:38 into the video:

So now is when the rubber meets the road.  The significant reforms the president has already implemented have been achieved mostly with the stroke of a pen.  Executive orders are easy.  Legislation is hard.  Very hard. And perhaps it’s why Mr. Obama preferred to rule by fiat.  Jason Riley of the Wall Street Journal effectively framed the issue of conservative resistance to this healthcare bill in a recent appearance on Fox News Sunday, starting at 4:28 in the video:

The two key points made by Riley are whether conservatives will persist in making “the perfect the enemy of the good” and that this legislation is being advanced not in a vacuum, but in a healthcare environment poisoned by the Obamacare death spiral.  In the end, though, the Republicans know that one way or another, they will assume full ownership of healthcare when the dust settles, so they better get it right or be prepared to pay a steep political price in the 2018 mid-term elections.