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It’s hard to think of a more make-or-break moment for Speaker Paul Ryan than what happens over the next two days. Well, sort of.

The speaker needs 216 votes to move his health care reform proposal on to the Senate. If he loses, then Ryan will have a difficult time rounding up the votes for the next tough vote (which is predicted to be tax reform).

And, if he wins, that’s the odd part. Then the bill moves to the Senate, where the most likely outcome is a major rewrite. And if that works, then it’s back to the House, where the same division between conservatives and leadership surfaces again. In the Republican Party there are three factions: conservatives, moderates, and those who fit into either camp but are yet inclined to support leadership. (That would be the majority of members in both the House and Senate.)

I think I’ve told this story before, but here goes again: Many years ago when I was at The Seattle Post-Intelligencer, we had an editorial board meeting with Rep. Jim McDermott. A tough vote was coming up in the House about the war in Iraq. We knew where McDermott stood. His inclination would be to vote no. But, he told us, “I will not do that to my speaker.” A no would have undermined Nancy Pelosi.

That’s not the way Congress works now. House conservatives do not fear the consequences of voting against their speaker (even though in the past it’s resulted in loss of committee assignments and the perks). They represent districts where they face little to no competition, so there is little the speaker can do to punish them. (This is not new. These are exactly the same dynamics that resulted in the end of .)

So the leadership challenge over the next two days is to make sure there are 216 votes to pass the American Health Care Act (after making minor changes). There are only three options: Make sure the votes are there; pull the bill back and rewrite it again; or, least likely, lose the vote and use that as a mechanism to try to punish the members who would not play along.

President Trump has his reputation (such that it is) on the line.

President Trump has his reputation (such that it is) on the line, too. He went to Capitol Hill trying to close the deal. According to Politico: “Trump entered the meeting to loud cheers. ‘We have a chance to do something fantastic, to do something amazing,’ Trump told the lawmakers, according to sources in the room. He later added: ‘Many of you came in on the pledge to repeal and replace Obamacare. I honestly think many of you will lose your seats in 2018 if you don’t get this done.’”

Once again, though, the polls show a different story. “A strong plurality of voters think congressional Republicans are moving too quickly to overhaul the nation’s health care system,” reported a new Morning Consult/POLITICO . This is the big reveal: The poll shows that the Affordable Care Act is more popular than the GOP alternative. This is not a prescription for winning the next election.

It makes it easier for any member of Congress who votes no to tell voters that they stuck up for their interests instead of following the speaker’s command.

Today the president will meet with the Congressional Black Caucus. He’s likely to make the case there, too. But Trump will have a tough time getting any votes from Democrats unless this health care bill changes into something quite different. The more I read about the legislation and the review by the Congressional Budget Office, it became clear that this bill is than a repeal of the Affordable Care Act. That’s where most of the “savings” in the bill are found.

The poll shows that the Affordable Care Act is more popular than the GOP alternative. 

There is a notion in the Republican reform (one that I find deeply troubling) that Medicaid is only another word for welfare. In this logic, people who are “able-bodied” are only gaming the system when they have this insurance. Nonsense. Health care is health care. Period. I think we should be expanding access to basic insurance, and Medicaid is a cost-effective program that works. I’d like to see Medicaid expanded, perhaps to cover people with incomes up to 300 percent of the federal poverty level.

Again, back to my Seattle days. We had an editorial board meeting on health care reform, and at that time the single largest source of Medicaid “customers” was people who worked at Wal-Mart. Fact is they had access to health insurance but could not afford it. And their incomes were so low that they qualified for Medicaid.

An increase in Medicaid eligibility would be a huge gain for Indian Country. That 300 percent number I cited would cover most of the people who use the Indian Health Service. If you then add the people who have employer-based insurance, I would bet you would be awfully close to universal coverage. And that ought to be the goal. (Working or not.)

Of course, the House plan goes in the other direction. on Tuesday that this bill is so bad that even a straight-up repeal of the Affordable Care Act would be better. “Getting rid of the major coverage provisions and regulations of Obamacare would cost 23 million Americans their health insurance, according to ,” The Times said. “In other words, one million more Americans would have health insurance with a clean repeal than with the Republican replacement plan, according to C.B.O. estimates.”

That little nugget is not going to help the speaker reach 216 votes on Thursday. If there is a vote.

This article was originally published at Trahant Reports. It has been edited for ¾«¶«Ó°Òµ Magazine.