If their latest Obamacare repeal efforts fail, Republicans really have only a few options. And each means political peril for President Donald Trump and Republican congressional leaders.

House members made progress Wednesday on the repeal and replacement bill, but there are still many hurdles, including overcoming some of the same challenges in bringing together conservatives and moderates if the bill reaches the Senate.


Alternatively, they could use executive powers to starve Obamacare by denying funding, while pushing regulatory buttons that unravel it. People would lose coverage, and the whole thing could collapse.

The other option is a more modest “repair” bill that keeps the foundation of Obamacare — such as the online marketplaces, the subsidies and Medicaid expansion — while addressing weaker parts of the law. That effort might even attract some Democrats but would be politically risky for a Republican Congress — and president — who campaigned for four election cycles on repealing Obamacare.

None of these options are great for Republicans politically, which is why Congress remains tied up in knots over how to fulfill one of its biggest promises.

Here’s a deeper look at the three choices on Obamacare.

If at first you don’t succeed …

With the defection earlier this week of key moderates like Fred Upton (R-Mich.) — the former Energy and Commerce chair who has written multiple bills dismantling Obamacare — the repeal effort was on the verge of crumbling again. GOP leaders insisted they’re not giving up the fight — partly because the alternatives aren’t very attractive. Upton early Wednesday reversed course and supported the bill after negotiating another $8 billion to help people with pre-existing conditions. It's the latest twist as Republicans have spent months trying to make good on their seven-year vow to repeal and replace Obamacare — only to find themselves stymied by their own members. Even if the bill now passes the House, it faces more travails in the Senate.

The GOP struggles this week have mirrored the problem House Republicans faced just six weeks ago, when the conservative hard-liners of the Freedom Caucus were largely responsible for scuttling the repeal effort because it didn’t take down enough of Obamacare. This time, centrists balked because it repeals too much — and puts popular protections for people with pre-existing conditions at risk.

“All that’s happened here is the blame, so to speak, has shifted from one part of the party to the other,” said John Rother, who was the top lobbyist at AARP for more than two decades and now works on drug costs.

“Not getting a bill done would be very detrimental,” said Mark Meadows (R-N.C.), who chairs the House Freedom Caucus. “I don’t know that you put any arbitrary deadlines on it, but obviously this week is a critical, critical week.”

Implode

The Trump administration could blow up the exchange markets simply by cutting off crucial subsidies that insurers are counting on to help provide coverage to low-income people — and OMB director Mick Mulvaney darkly hinted yet again Tuesday that it’s still a live option.

“We have not made any decisions,” he said at a press briefing. The May payments will be made, OMB later confirmed, but after that it’s an open question.

But Republicans risk being blamed for the ensuing mess as millions of Americans lose health care coverage — and in some states it could happen fast. Pulling the subsidy funding — valued at $7 billion this year — would likely prompt insurers to flee the individual market en masse. Swaths of the country would risk having no coverage options on the Obamacare exchanges, creating a crisis within a health care system that would by then be firmly under the Trump administration’s watch.

Already, insurers are warning that the White House is risking chaos. Insurers are getting ready to file their plans and proposed premiums for 2018 with regulators, some of whom are filing two sets of prices based on whether the cash keeps coming or not.

And even if the subsidies do flow, the foot-dragging isn’t inspiring much confidence in the administration’s broader commitment to keeping the insurance markets stable. Companies are well aware that Trump could still undermine Obamacare any number of ways, perhaps most simply by opting not to enforce the law’s individual and employer mandates.

Repair it

This is the most difficult scenario to envision right now, given the fire-breathing rhetoric on the right and the deep partisan divides and distrust in D.C. But the health care law covers roughly 20 million Americans — many of whom would be at risk of losing coverage or being forced to swallow skimpier benefits under the House bill. Much of what’s plagued the law could be fixed if Republicans and Democrats sought common ground, starting with releasing payments to insurers that Republicans have blocked and lowering the threat level on repeal.

“The president’s principles that he enunciated on the campaign … pretty much everybody can get around,” said Sen. Bill Cassidy (R-La.), referring to Trump’s call to ensure coverage for all. “It doesn’t have to be a large-scale rewrite.”

Obamacare is more popular than ever now too that it’s under threat, with voters more in favor of fixing than killing it. And on the Senate side, there may be some appetite for working across the aisle, starting with a plan by Cassidy and Sen. Susan Collins (R-Maine) that would give states the option of keeping Obamacare or shifting to a new system.

"It offers something that’s solid policy, with a bipartisan approach," Collins said.

Morning eHealth A daily report on the intersection of health care and technology — in your inbox. Email Sign Up By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Of course, taking the bipartisan route would mean first admitting defeat — a painful prospect in the early days of a Republican administration that was supposed to be all about winning.

“I believe we’re closer than ever on this,” Ways and Means Chairman Kevin Brady (R-Texas) said. “After seven years, many of us just believe when the time is right — sooner rather than later — let’s move.”

Still, there are plenty of big priorities left on the GOP’s agenda, and spending a few months focusing on less controversial health care issues — like reauthorizing the Children’s Health Insurance Program — might be the break lawmakers need before trying to tackle Obamacare once again.

“There’s a bipartisan caucus of members who want to have a serious discussion on those issues,” said Chris Jennings, a veteran Democratic health care strategist. “We just have to get past this endless and fruitless debate on repeal.”