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A day after a harsh judgment by the Congressional Budget Office on the House plan to repeal the Affordable Care Act, nervous Senate Republicans on Tuesday suggested changes to the bill. They told Trump administration officials – including the health secretary, Tom Price – that they wanted to see lower insurance costs for poorer, older Americans and an increase in funding for states with high populations of hard-to-insure people.

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The American Health Care Act is taking fire from all sides, not the least from the circular firing squad conservatives have formed, threatening passage of the only piece of repeal and replace legislation that House leaders say will be presented to members for a vote this year.

Conservatives may not like to hear it, but leaders and staffers have crafted what they believe is the best bill possible given the limits of the reconciliation process, the pressures of the legislative calendar, and the need to provide a safety net for those currently receiving ACA coverage.

Democrats want nothing more than to get Obamacare off their political backs. Any replace strategy is risky. But voting against “repeal” could be the death knell for Republicans in 2018.

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The furor over the Congressional Budget Office’s report on the House GOP health bill is concentrated on predictions about insurance coverage, which suits Democrats fine. Lost amid the panic is that CBO shows the bill is a far-reaching advance for the market principles and limited government that conservatives usually favor.

The CBO is not omniscient, but if its projections are even close to accurate then ObamaCare repeal and replacement is the most significant government reform in perhaps three decades. Under conventional (static-revenue) scoring, the bill cuts spending on net by $1.22 trillion and eliminates a raft of new taxes worth $883 billion through 2026.

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President Trump’s pick to run Medicare and Medicaid won confirmation Monday from a divided Senate as lawmakers braced for another epic battle over the government’s role in health care and society’s responsibility toward the vulnerable.

Indiana health care consultant Seema Verma, a protégé of Vice President Pence, was approved by a 55-43 vote, largely along party lines. She’ll head the Centers for Medicare and Medicaid Services, a $1 trillion agency that oversees health insurance programs for more than 130 million people, from elderly nursing home residents to newborns. It’s part of the Department of Health and Human Services.

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According to the CBO, able-bodied adults on Medicaid receive about $6,000 a year in government health-insurance benefits. They pay no premiums and minimal copays. You’d think that eligible individuals would need no prodding to sign up for such a benefit.

And yet, according to its analysis of the GOP ObamaCare replacement, the CBO believes that there are five million Americans who wouldn’t sign up for Medicaid if it weren’t for ObamaCare’s individual mandate. You read that right: Five million people need the threat of a $695 fine to sign up for a free program that offers them $6,000 worth of subsidized health insurance.

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The white smoke rose Monday afternoon from the Congressional Budget Office as the fiscal forecasters published their cost-and-coverage estimates of the GOP health-care reform bill. Awaiting such predictions—and then investing them with supposed clairvoyance—are Beltway rituals. The coverage numbers weren’t great for Republicans, but they shouldn’t allow an outfit that historically underestimates the benefits of market forces to drive policy.

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The non-partisan Congressional Budget Office has estimated that 24 million fewer people will have health insurance by 2026 under the House GOP plan to replace Obamacare. That projection is unsurprising, and quite likely overstated. But what is surprising about the CBO report is the ways in which it makes the GOP bill look better than expected, and how it points to how the bill can be improved. The bill would cut taxes by $1.2 trillion, and spending by $880 billion, for a net deficit reduction of $337 billion. And that’s before you take into account the macroeconomic effects that those tax cuts would have on economic growth, and thereby on greater tax revenues. Over ensuing decades, the fiscal impact would be even greater, because the bill entails the most significant effort at entitlement reform in American history. The bottom line: Republicans shouldn’t abandon the AHCA because of a superficially unflattering CBO score or its failure to meet their own purity tests. They should work all the more to correct its flaws. If they do, in 2020, the real world very well may vindicate them instead of the CBO.

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The draft legislative texts that will make up the American Health Care Act cleared two House committees this week amid vociferous complaints about the legislation, seemingly from all quarters. At some level this is understandable. After all, nobody expected the Democrats to stand up and applaud a replacement for the Affordable Care Act. And for Republicans, three other factors contribute. First, health-care reform is hard, and there are widely varying views of the best policy. Second, these are draft bills, not final legislation. The markup process is supposed to identify and modify unpopular provisions. Finally, the bill’s scope is limited by the budget reconciliation rules that fast-track Senate consideration. It is simply not possible to embody the full range of policy issues in a reconciliation bill, and some disappointment directly follows from what has had to be left out.

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The Senate is advancing Seema Verma, President Trump’s nominee to lead the Centers for Medicare and Medicaid Services.

Senators voted 54-44 Thursday on her nomination, which needed only a simple majority to overcome the initial procedural hurdle.

The Senate could take a final vote on Verma on Friday night, but her confirmation is expected to be kicked to Monday.

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