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Stunning as it is to witness the demise of the Republicans’ health reform effort, perhaps the most surprising piece is who played the role of executioner.

Moderates were widely expected to decide the fate of this bill, but no. In the end, it was brought down by two of the more reliably conservative voices in the Senate chamber — and just days after Senate majority leader Mitch McConnell accepted demands to move the bill dramatically right-ward.

This failure raises an ominous question for the whole Republican agenda. Looking beyond health care, will they ever be able to satisfy conservative purists and still assemble a coalition of 50 votes?

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The math is not auspicious. Republicans control a slim 52-seat majority in the Senate. Which means any trio of defectors can break a bill. And now we know there exist at least three conservatives willing to derail legislation in the name of deep principle or self-interest. But the precedent is now set, and it could haunt all future efforts.

The next big push is expected to involve tax reform. House Republicans have begun moving ahead with plans to overhaul the tax code and cut federal spending, but nearly all the details are TBD. Ditto from the White House, which has little to say about the nitty gritty even as it gears up for a nationwide push in support of big tax changes.

Many big questions remain unanswered. Should tax reform be revenue-neutral, with cuts in one area offset by closing loopholes? Or is the goal to cut taxes in hopes of super-charging the economy? Even if that means a widening deficit?

In politics, issues like these generally get worked out through compromise, horse-trading, and pressure from leadership. But that approach failed with health care, and there’s no reason to think tax reform will be easier.

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Sure, cutting taxes is an idea with a broad support in the Republican party — but the same could be said of repealing the Affordable Care Act.

Tax reform has a million different real-world meanings depending on which taxes you target, how much you choose to cut, and whether to seek out offsets. Just think back to the Republican primary, and the contrast between then-candidate Trump’s focus on tax rates and Ted Cruz’s preference for a whole new VAT-like system. Two big tax cut plans with little in common.

And before they even get to tax reform, Republicans might have a bigger problem on their hands: the debt ceiling.

Sometime this fall, the federal government will run up against an artificial limit on the amount of money it can borrow. If that happens, it could cripple government functions and damage the nation’s reputation as a safe place to invest.

The fix should be simple: Congress just has to pass a bill raising the limit. However, under former president Barack Obama, conservatives zealously resisted efforts to raise the debt ceiling, insisting on matching spending cuts and pushing the country to the brink of default.

Now that Republicans control the White House — and would probably get the blame for imperiling America’s credit and reputation — you might expect a change of tune. Defying Obama made political sense. Defying Trump is a different calculus altogether.

But passions on this issue run deep. And two of the senators who bucked leadership on the health care bill are also among the staunchest opponents of a simple increase in the debt ceiling, namely Mike Lee and Rand Paul. Add fiscal hawk Cruz to this mix and it’s possible Republicans will need Democratic support for a debt ceiling bill.

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Democrats have played this role before, joining with former House speaker John Boehner to avert a pair of fiscal crises in 2013. But many conservatives resented that cross-aisle outreach, and the tension contributed to Boehner’s decision to step down in 2015.

This time it’s not clear whether Democrats are ready to ride to the rescue, not without some inducement.

Again and again, in other words, Republicans are going to face this same problem. Committed conservatives unwilling to accept half a loaf — or three-quarters in the case of health care — can scuttle every effort to find 50 votes.

Presumably, conservatives hope that the lesson is plain. In future, leadership must bend to conservative demands if it hopes to make headway. But that only creates a new problem. When you reward one group of senators for their bad behavior, you encourage others to behave badly — threatening to walk unless their demands are also met.

And while McConnell is widely respected for his tactical acumen, it’s not clear he knows how to solve this problem.


Evan Horowitz digs through data to find information that illuminates the policy issues facing Massachusetts and the U.S. He can be reached at evan.horowitz@globe.com. Follow him on Twitter @GlobeHorowitz

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