We've known for months that Republicans could only go so far in repealing and replacing the Affordable Care Act via the budget reconciliation process (which allows them to circumvent Senate Democrats with just a simple majority instead of the typical 60 votes needed to break a filibuster). But those policy roadblocks took a back seat as conservative and more centrist Republicans aired their political concerns about the bill -- like whether it would preserve coverage for enough people or bring premiums down sufficiently so voters wouldn't punish them in future elections.

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Now policy problems -- what can and can't fit inside a budget reconciliation bill -- are back at the forefront, just as Senate Republican leaders try to push their members toward a planned vote this week on whether to start floor debate on a health-care bill. It's highly uncertain whether the vote to start debate on the bill will even succeed; if it does, Senate Majority Leader Mitch McConnell (R-Ky.) may bring up his Obamacare overhaul or he might substitute in a repeal-only bill.

Budget Committee Democrats indicated last week how Senate Parliamentarian Elizabeth MacDonough is leaning on elements of the Better Care Reconciliation Act. There are strict rules governing the process in the Senate: MacDonough must find that every provision is tied to federal spending; otherwise, Democrats can try to strike specific provisions from the legislation.

Passing a health-care bill without extra technical rules would have been hard enough. McConnell has yet to offer any legislation that 50 members in his conference support. But fitting a health-care bill through the narrow budget reconciliation hole might prove practically impossible for Republicans, forcing them to suspend indefinitely their Obamacare repeal effort.

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Planned Parenthood defunding is a good example of this problem. MacDonough has indicated that the ban, as written, wouldn't comply with reconciliation rules because it singles out a health provider. Planned Parenthood hailed her guidance, saying last week that it showed Republicans were singling their group out for punishment.

“No amount of legislative sleight of hand will change the fact that the primary motivation here is to pursue a social agenda by targeting Planned Parenthood,” said Dana Singiser, the group’s vice president for public policy and government affairs, in a statement.

A Senate bill that preserves Medicaid reimbursements for Planned Parenthood could feasibly pass the Senate, and even remove roadblocks for GOP Sens. Lisa Murkowski of Alaska and Susan Collins of Maine, who support abortion rights. But should such a bill go back to the House for approval, there could be a major revolt among conservative Republicans who have promised their base they'd target the country's largest abortion provider and who look to antiabortion groups for their cues.

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Rep. Trent Franks (R-Ariz.), chairman of the House Pro-Life Caucus, tweeted a warning last month:

Several abortion-opposing groups including the Susan B. Anthony List, the Family Research Council and the National Right to Life tentatively backed the Senate health-care bill last week under the assumption it would defund Planned Parenthood. They're not withdrawing support quite yet, holding out hope that Republican staffers will be able to tweak the language so that it complies with the so-called "Byrd rule" governing the reconciliation process.

"The news from the parliamentarian was another dip in the roller coaster ride," SBA List President Marjorie Dannenfelser told me yesterday. "We have been reassured the problem can be fixed, so are in a tentative support mode still."

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Dannenfelser, along with representatives from organizations such as Concerned Women for America, the National Taxpayers Union, American Conservative Union, Club for Growth, the U.S. Chamber of Commerce and the National Federation of Independent Businesses, met with Vice President Pence on Friday to talk about Obamacare repeal.

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“Every one of the groups that are gathered here today — the millions that you represent — are here to speak with one voice to say to the Congress: It’s time to vote. It’s time to act,” Pence told the group. “It’s time to get on with a debate to repeal and replace Obamacare.”

But Democrats are gleeful at the guidance from MacDonough, who advised party leaders that roughly a dozen provisions in the Senate bill may not meet th Byrd rule requirements and would need 60 votes to pass, meaning that 52 Senate Republicans could not pass the measures on their own. From Budget Committee ranking member Bernie Sanders (I-Vt):

Senate Democratic leader Chuck Schumer chimed in, too:

AHH, OOF and OUCH

AHH: Two leaders of the House Freedom Caucus criticize the Congressional Budget Office in a Washington Examiner op-ed, writing that the nonpartisan agency has a "strong reputation among the public and the media" but its track record of providing accurate estimates "leaves much to be desired."

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“Beyond short- and long-term budget projections, CBO has also proven grossly ineffective at forecasting consumer choices. Nowhere is this more clearly seen than the Affordable Care Act," HFC Chairman Mark Meadows (R-N.C.) and former chairman Jim Jordan (R-Ohio) write. "CBO economists are trained to apply Keynesian economic formulas to predict future consumer behavior, but their projections don't often account for common-sense realities, such as the wet blanket effect that Obamacare had on job creation and economic growth. Time and time again, their projections miss the mark because they don't consider economic reality.”

“Fast-forwarding to today's debate over replacing the ACA, the CBO has once again weighed in with a doomsday projection about how many people would lose coverage if either the House or Senate reform bills pass. Unfortunately, we believe the CBO has missed the mark again," the two write.

--Although the CBO's current director, Keith Hall, was appointed by a Republican Congress, the Trump administration and some congressional Republicans have argued that the methods the agency uses are unsound and that its staff favors the Democratic agenda. Former CBO directors pushed back on Friday, publishing a letter to Congress in which they defended the agency.

“Relying on CBO’s estimates in the legislative process has served the Congress — and the American people — very well during the past four decades,” the authors write. The signatories of the letter include Douglas Holtz-Eakin, a conservative supporter of the GOP effort to dismantle Obamacare, as well as Peter Orszag, who served as budget director in the Obama administration.

OOF: An Arizona woman who lost to Sen. John McCain (R-Ariz.) in the Republican primary last year is urging the ailing senator to think about stepping down -- because she might want to nab his seat. A day after McCain announced his brain-cancer diagnosis, GOPer Kelli Ward asked the senator to think "long and hard" about remaining in the Senate, The Post's Kristine Phillips reports. Ward is currently running to unseat Arizona's other senator, Republican Jeff Flake.

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“I hope Sen. McCain is going to look long and hard at this, that his family and his advisers are going to look at this, and they’re going to advise him to step away as quickly as possible," Ward said last Thursday during an interview with an Indiana radio station. In a statement posted later on her website, Ward said McCain’s cancer is “both devastating and debilitating” and he “owes it to the people of Arizona to step aside” when he’s no longer able to perform his duties.

McCain’s office announced Wednesday that he’d been diagnosed with glioblastoma, an aggressive type of brain cancer. The diagnosis and a subsequent surgery raised questions about when and if he will go back to the Senate, prompting McConnell to delay a vote on the GOP health-care bill.

OUCH: The pro-Obamacare group "Save My Care" is pressuring three key Senate moderates to vote against the Senate bill, The Hill reports. The six-figure ad buy targets Sens. Dean Heller (R-Nev.), Shelley Moore Capito (R-W.Va.) and Lisa Murkowski (R-Alaska).

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"Senator Heller promised to protect our healthcare, but he refuses to take a stand, even though the bill slashes Medicaid and over 100,000 Nevadans will lose insurance," the narrator says in the ad targeting Heller, who also faces a tough reelection race next year. "Senator Heller, stand up for Nevadans, vote no on healthcare repeal."

TRUMP TEMPERATURE

--Trump is piling, nay, heaping the pressure on Senate Republicans to pass an Obamacare repeal bill this week. The president plans to deliver a statement on health-care at 3:15 this afternoon, according to the White House. After the statement, Trump will participate in a "greeting with victims of Obamacare."

Trump is also dropping by West Virginia, making an appearance at the Boy Scouts of America's 2017 National Scout Jamboree in Glen Jean, the Williamson Daily News reports. One of the state's senators, Shelley Moore Capito, has recently been standing in the way of passing the president's top legislative priority -- an Obamacare overhaul. If the two aren't getting along when it comes to policy, at least Capito had some nice things to say in her news release.

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"I'm thrilled President Trump will be making his first trip to West Virginia as president on Monday," Capito said, according to the statement. "At the Jamboree, the president will have an opportunity to see the future leaders of our country. I look forward to welcoming him to the Mountain State."

Trump expressed his frustrations with the imploding effort over the weekend:

It's clear Trump is deeply cognizant of his promise to sign an Obamacare repeal bill on "Day One" of his presidency. This tweet could be referring to health care:

Or, Trump may have been referring to the Russia scandal, noted the New York Times's Trip Gabriel:

From the NYT's Maggie Haberman:

--The president also urged the public to call their members of Congress and ask for an Obamacare repeal bill.

"Call that congressman and call that senator, and make sure you get it,” Trump said at a ceremony commissioning the newest U.S. aircraft carrier, referring to military spending. "And by the way, you can also call those senators to make sure you get healthcare."

--After meeting with conservatives on Friday, Pence called again on Republicans to pass a health-care bill at an address on Saturday.

"A few Republicans in the Senate weren't quite ready to move forward on legislation to repeal and replace Obamacare," Pence said during his keynote address at the Ohio Republican Party state dinner. "Now some people around the country harbor the belief that Democrats will help us clean up the mess they made, but as I said, and the President said this morning, Republican senators must step up to the plate after seven years and vote to repeal and replace Obamacare."

HEALTH ON THE HILL

--Buckle up your seatbelts. Senate Republican leaders have indicated they want to hold a vote this week on starting health-care debate, possibly on Tuesday. But there are tons of outstanding questions -- like whether McCain (a crucial vote for Republicans) will be able to return to Washington in time, whether there will even be 50 GOP votes to bring a bill to the floor at all and whether McConnell will bring forward his bill replacing the ACA or a bill just repealing parts of it.

Sen. Collins, who is almost certainly a "no" vote no matter what, said Sunday that she has no idea what version of a health-care bill Republican rank-and-file will be asked to vote for.

"It's a good question about what's going to be happening next week," Collins said on CBS' "Face the Nation." "It appears that we will have a vote on Tuesday. But we don't know whether we're going to be voting on the House bill, the first version of the Senate bill, the second version of the Senate bill, a new version of the Senate bill, or a 2015 bill that would have repealed the Affordable Care Act now and then said that somehow we'll figure out a replacement over the next two years."

"I don't think that's a good approach to facing legislation that affects millions of people and one sixth of our economy," Collins added.

No. 3 Senate Republican John Thune (S.D.) said yesterday that if the Obamacare repeal efforts collapse this week, Republicans will “go back to the drawing board” and try again. “What will happen is, if and when that were to occur, we’ll go back to the drawing board and get a bill up,” Thune told "Fox News Sunday" per Politico. “We are going to vote to repeal and replace Obamacare. It’s not a question of if, it’s a question of when.”

--Meanwhile, activists on both sides are keeping the pressure on. This morning at 10 a.m. the Tea Party Patriots are planning to deliver 1.5 million signatures to McConnell's personal office in the Russell Senate Office Building, a spokesman tells The Health 202.

Senate Democrats noted all the confusion around Capitol Hill about a path forward. From part of a tweetstorm from Sen. Chris Murphy (D-Conn.):

From Sen. Dianne Feinstein (D-Calif.):

From Sanders:

--Hear that whimper? It's from House Republicans, who are set to depart next week for a five-week summer recess with their biggest legislative priorities up in the air. Hopes of passing a 2018 budget remain in limbo, and that has to be done before Republicans can move onto the tax overhaul Speaker Paul D. Ryan (R-Wis.) has promised to deliver before the year's end, my colleague Mike DeBonis reports. Also unclear: Whether the chamber will be able to secure border wall funding or a sanctions targeting Iran, Russia and North Korea.

"Passing only some — or even none — of these bills could make it an uncomfortable summer for GOP lawmakers, who are part of a federal government under unified Republican control for the first time in a decade yet have struggled to deliver major legislative victories," Mike writes.

And then there are health-care and a tax overhaul -- two core items on the Trump agenda.

"Since passing a health-care bill in May, the House watched the Senate flounder on the issue, and the failure of an expected Senate vote on the issue next week could leave the legislation in permanent limbo," Mike writes. "A group of hard-line conservatives is pressing House leaders to vote on an Affordable Care Act repeal bill next week, but leaders and other members feel no compunction to act until the Senate breaks its impasse."

"The much-anticipated tax reform bill, meanwhile, is caught up in the complex politics of GOP budgeting," he continues. "Because Republicans expect to use special procedural rules to skirt a Democratic filibuster in the Senate and pass a bill with only GOP votes, they must first pass a budget resolution."

MEDICAL MISSIVES

--The Royal Courts of Justice in London will hear testimony this week in the case of Charlie Gard, a terminally ill 11-month-old. Charlie has mitochondrial DNA depletion syndrome, a rare genetic condition that has robbed him of the ability to see, hear, move or breathe on his own, The Post's Cleve R. Wootson, Jr. reports. His doctors at Great Ormond Street Hospital (GOSH) have concluded that nothing more can be done for him and he should be taken off life support, but his parents want him to undergo an experimental treatment in the United States that they say could help.

In a pretrial hearing Friday, emotions were running so high that his parents stormed out, cursing and sobbing. After an attorney for GOSH told a judge that there was an updated brain scan on the terminally ill baby, but that it made for “sad reading," Charlie’s father, Chris Gard yelled “evil,” and then “I'm not f------ listening to this biased s--- anymore,” according to CNN. Charlie’s mother, Connie Yates, began sobbing as the couple stormed out of the courtroom.

Protesters who want Charlie to receive an experimental medical treatment rallied outside the courthouse on Sunday, according to the Associated Press, including some who'd come from as far as the United States. Others have sent death threats to the hospital treating him.

“In recent weeks the community has been subjected to a shocking and disgraceful tide of hostility and disturbance,” the Great Ormond Street Hospital said in a statement. “Staff have received abuse both in the street and online. Thousands of abusive messages have been sent to doctors and nurses whose life's work is to care for sick children.

“Many of these messages are menacing, including death threats. Families have been harassed and discomforted while visiting their children, and we have received complaints of unacceptable behaviour even within the hospital itself.”

The hospital said it had been in contact with police and “will do everything possible” to hold people responsible for the threats.

So far, other courts have sided with Charlie’s doctors, who say the treatment is a fruitless endeavor that has not been tested on someone with Charlie’s specific condition and that it will only cause the baby more pain. But Charlie’s parents have garnered support from President Trump, Pope Francis, U.S. lawmakers and antiabortion groups.

DAYBOOK

Today

President Trump is scheduled to give a statement on health care this afternoon.

The National Press Club will host House Freedom Caucus Chairman Mark Meadows (R-N.C.) to discuss the Republican health care effort. Coming Up The DC Society of Health Policy Young Professionals and the Government Affairs Industry Network host an event on the future of health care reform on Tuesday .

. The Bipartisan Policy Center hosts an event on The Future of Comparative Effectiveness Research on Tuesday .

. The House Energy and Commerce Subcommittee on Health will hold a hearing on examining the extension of special needs plans on Wednesday .

. The Hill is hosting an event on health care affordability and access on Wednesday .

. Bloomberg Government hosts an event on the cost of health care on Wednesday .

. A health-care rally is planned for Saturday in Washington, D.C.

SUGAR RUSH

The White House spin on the CBO, annotated:

Incoming White House Communications Director Anthony Scaramucci perceives 'a little bit of media bias':

Sean Spicer's exit reveals the perils of being Trump's mouthpiece:

Can the president pardon himself?