The next 10 days could change American healthcare for decades

After seven years of promising, Republicans are closer than ever before to repealing and replacing Obamacare. On Thursday, they are expected to reveal the latest iteration of the Trumpcare bill, with plans to put it to a vote by the end of next week. With tax reform still in primordial form, and a much-ballyhooed infrastructure package nowhere to be found, the repeal of the Obama-era healthcare bill has emerged as the defining political battle of President Donald Trump’s young presidency.

The next 10 days could change the course of the American healthcare system, and the two parties fighting over it, for decades to come. Here’s what you need to know:

On Thursday at 11:30 a.m., Republican Senate Majority Leader Mitch McConnell of Kentucky will unveil the fourth version of the healthcare bill to his Republican colleagues, with hopes of a vote by the end of next week.

In secret, and without any congressional hearings, McConnell has been haggling with both sides trying to craft a bill that will somehow satisfy at least 50 of the 52 Senate Republicans, several of whom who rejected the last version of the bill for a variety of ideological reasons. The details have been kept close to the vest, but the new bill is expected to devote more money to the opioid crisis — though not enough to offset the cuts to opioid treatment through the bill’s Medicaid changes. According to the Wall Street Journal, it is also expected to remove some of the previous tax cuts that went to the wealthy, though the bill is still likely to cut taxes by several hundred billion over the next decade.

We will learn even more details about the bill on Monday, when the Congressional Budget Office is expected to release its analysis. It is still likely that by 2026, around 20 million fewer people will have health insurance because of the bill’s reforms to Medicaid and the private insurance market — as reflected in the previous CBO analyses.

Yes. There are enormous obstacles to overcome, and many Republican senators have been publicly pessimistic about the bill’s chances. But there’s an argument that Republicans will end up deciding that voting yes is the better path, both politically and policy-wise.

As it is now, most Republicans believe they are stuck with two bad options. Though the bill is polling below 20 percent, some aides to Republican Senators that say that passing nothing would be even worse. With control of both houses of Congress and the White House, a failure to pass a significant piece of legislation in Trump’s first 7 months would likely dispirit the conservative base as an indictment of Republican leadership.

Conservatives are also advancing the argument that the bill offers a rare policy opportunity to roll back and reform a government entitlement. “We’ve been dreaming of this since I’ve been around—since you and I were drinking at a keg,” Paul Ryan said of the state-centered reforms and caps on Medicaid in an interview with the National Review’s Rich Lowry earlier this year.

While most Republicans agree the bill is not perfect, leaders believe it is their best chance to enact a conservative solution to healthcare. “I think this bill is better than Obamacare,” Sen. Lindsey Graham of South Carolina, a frequent critic of the president, said on Meet the Press last Sunday. “I would support the proposal before us.

If Sen. Ted Cruz of Texas does not vote “yes,” it is unlikely that the bill will pass.

That’s why senators will be paying very close attention next week when the CBO releases its report on the Trumpcare legislation. The CBO is reportedly analyzing not one but two separate Trumpcare bills: one with, and one without, a proposed amendment from Cruz and fellow conservative Mike Lee of Utah. Many senators, including conservatives like Chuck Grassley of Iowa, have expressed deep reservations about the Cruz-Lee amendment — but without its inclusion, Cruz has threatened to vote no.

The amendment would allow insurance companies to provide alternative plans that do not comply with Obamacare’s required essential benefits. Experts argue that this would likely divide the healthcare insurance market between the sick and the healthy, undermining the very concept of insurance.

Proponents of the amendment argue that it would restore the private marketplace and create a well-funded high-risk pool, as sick people would likely opt for Obamacare-compliant plans, which qualify for federal subsidies.

On Wednesday, the amendment met with some preemptive resistance from the insurance industry. “Unfortunately, this proposal would fracture and segment insurance markets into separate risk pools and create an un-level playing field that would lead to widespread adverse selection and unstable health insurance markets,” wrote America’s Health Insurance Plans, a trade association for insurance companies.

Democrats are united in opposition to Trumpcare and have begun paying for ads attacking Republicans for the bill. On policy, Democrats announced before Trump was inaugurated that they would not join Republicans in their attempts to gut Barack Obama’s most high profile legislative accomplishment.

Even moderate senators up for reelection in 2018 in states Trump won, like Heidi Heitkamp of North Dakota and Joe Manchin of West Virginia, are opposed to the bill, which would devastate their rural communities and citizens affected by the ongoing opioid epidemic. Both have criticized the Obamacare status quo, and offered to work with Republicans to shore up the healthcare marketplaces. Heitkamp also proposed legislation just this week, but Republicans are focused for now on the larger Trumpcare bill. Without any Democrats on board, McConnell can only lose two votes of his 52. If that happens then it’s a 50-50 tie and Vice President Mike Pence would cast the deciding vote.