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The fight to repeal Obamacare is, in my view, not dead. The Senate lost a crucial battle this week, but as long as Republicans control Congress, they plan to keep fighting the war.

“We are going to fulfill our promise to repeal and replace,” Sen. Lindsey Graham (R-SC) promised at a press conference announcing there would be no vote on his proposal with Sen. Bill Cassidy (R-LA).

The fight to repeal Obamacare remains, but the obstacles going forward will be significantly bigger. Wiping the Affordable Care Act off the books only gets harder from here for a handful of reasons:

House Republicans would need to pass an entirely new bill. Back in May, it looked like House Republicans had gotten through the hardest part: They'd found a bill that could satisfy both moderate and conservative members of their caucus. But now it's become apparent that the Senate won't pass the House-approved American Health Care Act. They've spent nine months coming up with different health care bills rather than bring up what the House passed.

This means that going forward, the House will almost certainly have to vote a second time to repeal the Affordable Care Act. And they'd likely need to vote on a bill from the Senate they don't like nearly as much as their own.

Getting one Obamacare repeal bill through the House was tough. Doing it a second time — when it's not even the bill they'd choose — is even harder.

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There aren't that many opportunities to move bills through the reconciliation process. Republicans have homed in on the reconciliation process as their path toward repeal, and for good reason: It allows the Senate to pass bills with a 51-vote majority so long as that bill is focused on budgetary matters.

Vox's Andrew Prokop has dug into the weeds of Senate policy and finds there is indeed space for Republicans to pursue at least two more budget reconciliation bills before the end of December 2018, after which they may no longer control both chambers of Congress. Republicans now seem pretty set on using that first budget reconciliation bill to pursue tax reform, but could use a second bill for 2019 to once again attempt to repeal Obamacare.

"If we can’t do it in a reconciliation vehicle this year, then maybe it’s the 2019 [budget]. I don’t know," Sen. John Thune (R-SD) recently told Politico. "We’ll see.”

Yes, that is a chance to repeal the Affordable Care Act — but it's an awfully narrow one. It reminds me of a moment in the Jim Carrey movie Dumb and Dumber when his love interest tells him that the odds of them dating are roughly "one in a million."

To which Carrey responds, enthusiastically:

There is certainly a chance for Republicans to repeal Obamacare — the chances are probably better than one in a million! But they're not great because the party is constrained to using the reconciliation process and only has a few more cracks at that left in the coming year.

There is no clear ground between the Senate moderates and conservatives. Any future Republican repeal efforts will confront the same obstacle as those we've seen fail in recent months. There appears to be no policy middle ground between someone like Sen. Rand Paul (who wanted to see the insurance markets completely deregulated) and Sen. Susan Collins (who wanted to ensure nobody in her state lost coverage).

Any future Obamacare repeal attempts will confront the fact that Republicans aren't united on what they want to replace the Affordable Care Act with. That obstacle sunk the previous repeal plans and remains a really big hurdle for any attempts going forward.

Chart of the Day

Anthem exits Maine, but leaves behind two carriers in each county. Yes, this is a bit of a boring map. But it's a map with a good news story: None of the Maine counties will be left bare after Anthem's announced exit Wednesday. They will each have two options: Community Health Options (one of the remaining Obamacare co-ops) and Harvard Pilgrim.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

News of the day

“Alexander, Murray to meet for bipartisan health talks”: “GOP Sen. Lamar Alexander will meet with Democratic Sen. Patty Murray on Wednesday to try to salvage their bipartisan health care efforts, Alexander said in an interview. House and Senate Republican leaders rejected the effort last week, preferring instead to try another partisan attempt at Obamacare repeal.” —Burgess Everett, Politico

“GOP Sen. Lamar Alexander will meet with Democratic Sen. Patty Murray on Wednesday to try to salvage their bipartisan health care efforts, Alexander said in an interview. House and Senate Republican leaders rejected the effort last week, preferring instead to try another partisan attempt at Obamacare repeal.” —Burgess Everett, Politico “Trump preparing executive order to let Americans purchase health insurance across state lines”: “President Trump is preparing an executive order to allow people to purchase health insurance across state lines, a reform conservatives have long championed as a way to bring costs down and stir greater competition in the national marketplace.” —Gabby Morrongiello, Washington Examiner

“President Trump is preparing an executive order to allow people to purchase health insurance across state lines, a reform conservatives have long championed as a way to bring costs down and stir greater competition in the national marketplace.” —Gabby Morrongiello, Washington Examiner “Trump unhappy with top health official over travel”: “President Donald Trump declared Wednesday he’s “not happy” with his top health official, after Tom Price’s government-paid travel on costly charter flights triggered a wide-ranging congressional investigation of the administration. Trump’s displeasure, voiced repeatedly, called into question Price’s job security as head of the Health and Human Services Department.” —Associated Press

​Analysis and longer reads

“Puerto Rico Rushes to Patch Up Health-Care System Ravaged by Hurricane Maria”: “Securing more fuel for generators and clean water for patient care are “two important priorities” for the island’s hospitals and clinics, said Kenneth Sturrock, the federal health coordinator for the U.S. Department of Health and Human Services who was on the ground in Puerto Rico on Tuesday. The National Disaster Medical System has sent 330 health-care workers from the U.S. mainland to assist Puerto Rico, he said, and U.S. lawmakers are pushing for quick approval of hurricane aid.” —Betsy McKay, Melanie Evans, Daniela Hernandez and José de Córdoba, Wall Street Journal

“Securing more fuel for generators and clean water for patient care are “two important priorities” for the island’s hospitals and clinics, said Kenneth Sturrock, the federal health coordinator for the U.S. Department of Health and Human Services who was on the ground in Puerto Rico on Tuesday. The National Disaster Medical System has sent 330 health-care workers from the U.S. mainland to assist Puerto Rico, he said, and U.S. lawmakers are pushing for quick approval of hurricane aid.” —Betsy McKay, Melanie Evans, Daniela Hernandez and José de Córdoba, Wall Street Journal “Graham-Cassidy Failure No Relief For Insurers”: “Even in failure, the push for Graham-Cassidy has hurt the insurance market, by derailing a bipartisan effort to stabilize the ACA exchanges. By the end of Wednesday, insurers must tell most states whether they'll participate in the exchanges next year. There are rumblings that congressional stabilization work may start again, but it seems unlikely to succeed at all, let alone in time to have a large impact on the market in 2018.” —Max Nisen, Bloomberg

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