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The Republican health care gambit reaches a crossroads

Two Republican senators already oppose their party's health care bill. Health care advocates need a third.
(FILES) This file photo taken on October 17, 2013 shows the US Capitol building before sunrise in Washington, DC. ...

While the details of health care policymaking may be complex, the arithmetic of health care legislating is not. There are 52 Senate Republicans, and to pass the GOP's regressive health care overhaul, the party will need 50 votes (plus Vice President Mike Pence to break the tie).

If two Republican senators break party ranks and oppose the bill, it passes. If three or more do so, it dies.

In June, when Senate Majority Leader Mitch McConnell (R-Ky.) unveiled the original iteration of his blueprint, it was a full day before any GOP senator spoke out against the plan. As Slate's Jim Newell explained, the developments yesterday, with the release of McConnell's amended package, unfolded much faster.

Maine Sen. Susan Collins did not take very long, after seeing the new version of the Republican health care bill in a meeting on Thursday morning, to announce that she would not support it. She listed the many, many problems she still had with the bill, such as the cuts to traditional Medicaid -- which remain just as they were in the first version of the bill. She would also vote no on the motion to proceed, the procedural vote that sets up debate on the bill. She is gone.Kentucky Sen. Rand Paul also wasted no time after the meeting to declare that he, too, would vote no on the motion to proceed, from the opposite end of the spectrum.... He will not vote to proceed. He is gone.A funny thing happened, though, after Collins and Paul immediately announced that they would not vote to advance the bill: No one else did.

This left health care advocates with a sense of uncertainty. On the one hand, opponents of the far-right approach were encouraged by the fact that the Republican plan was already struggling, just hours after its unveiling. On the other hand, two "no" votes won't be enough to stop the bill. One more is needed.

What's unclear is whether some GOP senators who balked at the plan in June will find a way out of the box they've put themselves in.

There are plenty of head-counts available, showing where the various members stand -- the New York Times' version looks the most accurate to me -- but I'm especially interest in Nevada's Dean Heller and Alaska's Lisa Murkowski, two Republicans who opposed their party's plan last month.

Heller, in particular, said he simply couldn't go along with legislation that made such brutal cuts to Medicaid and undermined those with pre-existing conditions, and when he announced his opposition, the Nevada Republican left himself no wiggle room. And therein lies the rub: the newest version of the GOP plan leaves those same Medicaid cuts intact and is arguably even worse for Americans with pre-existing conditions.

Heller, in other words, has backed himself into a corner. Either he honors the concerns he raised just a few weeks ago, or reverses course and completes a very public betrayal -- the year before his re-election campaign.

Murkowski is in a similar boat, having balked at the Medicaid cuts Republican leaders have left in the bill. To be sure, Mitch McConnell has gone out of his way to help Murkowski's Alaska, in particular, with specific carve-out provisions, but she's also on record saying her vote couldn't be bought off with a special deal for her home state -- because she was also concerned with the nation's interests overall.

I don't doubt that the pressure will be overwhelming, and the urge to put the party's interests above the nation's will be real, but how do senators like Heller and Murkowski reverse course now?