Seven years and one day after President Obama’s signature piece of legislation the Affordable Care Act was signed into law, Republicans face an ultimatum from the White House the day Congress is set to vote on a partial replacement bill — the American Healthcare Act.

The bill received an initial Congressional Budget Office score that indicated it would leave at least 14 million fewer Americans with healthcare by 2018, and around 24 million by 2026. Additionally, premiums were predicted to increase sharply over the next two years before stabilizing and the bill was estimated to reduce the federal budget by about $337 billion over the next ten years.

A revised version of the bill intended to satisfy House freedom caucus members received a similar score, with the CBO predicting that it would result in the same number of Americans losing health insurance. The biggest difference was the estimate that the new version would reduce the budget by a significant amount less, around $151 billion compared to the original prediction of $337 billion.

After a vote on the AHCA scheduled for Thursday in the House failed to manifest due to divisions amongst Congressional Republicans, reported late-night negotiations by the White House devolved into an ultimatum that it’s now or never — either vote for Trumpcare or Obamacare stands.

The dramatic showdown putting President Trump’s reputation as a dealmaker on the line is the result of a highly factionalized Republican Party struggling to compromise and govern. As former Speaker John Boehner noted a couple years ago, “My goal every day is to try to keep 218 frogs in a wheelbarrow long enough to get something passed.”

As Nate Silver and I have both noted, Republicans really have no where to go from here. It’s a lose-lose either way, if they pass their bill and cause millions of Americans to lose health insurance while sending premiums skyrocketing the electoral consequences could be devastating. Yet if they fail to keep the promise that energized the entire Tea Party movement, they’ll have to explain it to the voters who sent them to D.C.

Regardless of the political calculus that Congressional Republicans end up making, they’ll have to choose soon. Today is the day of the ultimatum, and a vote on the AHCA should take place in a matter of hours.