President Donald Trump may rally Republicans on a strategy to repeal and replace Obamacare in his speech to Congress Tuesday night. But the reality is his administration still has to contend with huge divisions within the GOP that have turned its top policy goal into a long and uncertain slog.

Republicans lack consensus on such basic questions as how much to spend to reshape the health system, how much financial help to give Americans to buy insurance and how to come up with the money to pay for it all.


The GOP hoped to march into Washington with unified control over the government in January and quickly scrap the law Republicans repeatedly promised would be eliminated. But they got stuck, to the delight of Democrats. The leak of the House’s draft legislation last week shows just how far Republicans have to go on a bill that can win over the disparate factions of the party and the public.

Here are the biggest hurdles facing the GOP:

— What kind of assistance should people get — and how much?

Many Republicans agree that Americans should get some help with buying health insurance — an alternative to Obamacare’s subsidies. But conservatives are somewhat skeptical, warning that they won’t support tax credits for recipients that could become a “new entitlement.” The leaders of two House conservative groups — Republican Study Committee and House Freedom Caucus — on Monday said they wouldn’t support the repeal legislation because of its refundable tax credits, which they liken to a new entitlement.

“It kicks the can down the road in the hope that a future Congress will have the political will and fiscal discipline to reduce spending that this Congress apparently lacks,” Republican Study Committee Chairman Rep. Mark Walker (R-N.C.) said. “Worse still the bill contains what increasingly appears to be a new health insurance entitlement with a Republican stamp on it.”

— What is the price tag and how to pay for it?

Republicans have to resolve several critical questions that will have a big effect on the price tag of a repeal-replace bill. One area where the GOP has to find consensus is how many Obamacare taxes to repeal. After initially saying all the taxes should go, some Republicans now think they should be retained, if only partially, to help cover the cost of the GOP replacement.

An even more controversial way to pay for the bill is the proposal from House leaders to cap the tax credit that employers get for providing health insurance to their employees. The policy is considered an alternative to Obamacare’s Cadillac tax on high-cost health insurance plans. Both are hated by employers and unions.

Those who want to cap the tax break say that the idea of tying health insurance to a job is a World War II-era relic that no longer makes sense in a mobile economy. But even they admit it is politically unpopular.

“The idea of changing, that makes sense,” said Rep. Mark Sanford (R-S.C.). “The question of having some cap at $30,000 and anything above that is in essence a de facto tax increase, is something that’s probably going to give a lot of Republicans pause.”

— How to deal with states that expanded Medicaid versus those that didn’t?

Republicans want to dramatically overhaul the Medicaid entitlement by giving states a fixed amount of money tied to the number of residents enrolled. But first, they have to prevent a food fight between the states that expanded Medicaid under Obamacare, a mix of Democratic- and Republican-led states, and those that held out, a group consisting of almost entirely red states.

The states that didn’t expand their Medicaid programs are poised to get significantly less money than the states that did opt in. Republicans are now figuring out how to make sure they’re not financially punished for rebuffing Obamacare.

“We’re going to have to find a solution that accommodates each of these two concerns,” House Speaker Paul Ryan said before the Presidents Day break.

The House is considering setting up special funds for the uninsured, which would provide a boost to the non-expansion states. But any governor that feels slighted is sure to make noise during the legislative debate over the bill.

— Can the House bill pass the Senate?

Senate Republicans have largely held their fire while the House works on repeal-replace legislation. But there are already signs that whatever passes the House won’t sail through the upper chamber. Sen. Lisa Murkowski (R-Alaska) last week drew a line over rolling back Obamacare’s Medicaid expansion, saying she wouldn’t vote for a bill that repeals it if her state legislature wants the expansion to remain in place. The 52-member Republican conference can only afford to lose two votes before Vice President Mike Pence would have to come in to break a tie, meaning Republican swing votes like Murkowski could leave an outsize imprint on a final agreement.

— Do they have the guts?

Support for Obamacare is hitting record highs, any Republican bill is sure to be scored as increasing the uninsured rate and the 2018 mid-term election is getting closer and closer.

After seven years of rallying against Obamacare, how many Republicans are going to get cold feet about, as the campaign ad might say, ripping health care coverage away from millions of vulnerable Americans?

The strategy from GOP leaders is that no elected official with an "R" after his or her name can vote against Obamacare repeal without getting a primary challenge.

“This is not atypical of a lot of big policy fights. You have to be a phoenix here — be able to go up in flames and come back,” said Sage Eastman, a principal at Mehlman Castagnetti who is following the health care debate. “This is now the moment where members get to see all the good and all the bad and it’s a tough vote and you have to come to grips with it.”