Republicans have reached a gut check moment: After spending more than six years vowing to fix the flagging patient that is Obamacare, it’s the GOP’s own repeal effort that’s on life support.

Undoing the health care law despised by conservatives seemed to be a straightforward proposition for the party after it won the White House and retained control of both chambers of Congress. Instead, Republicans are sniping over how much of the law to scrap, what to replace it with and when. At this moment, it's far from a sure thing any plan could get through Congress.


Consider Paul Ryan's feel-good meeting with Senate Republicans on Tuesday. The House speaker trekked across the Capitol to reassure senators that lawmakers are making more progress toward repealing the health care law than the media are reporting.

But not everyone was buying it. Sen. Rand Paul (R-Ky.) left before it was over, having heard enough of a conversation that he says centers around keeping Obamacare's Medicaid expansion intact and creating tax credits that he called a "new entitlement program," though a Republican in the room rebutted the notion that the topic of Medicaid expansion came up in the Tuesday meeting with Ryan.

“I hear things that are unacceptable to me,” Paul said in an interview afterward. “If they don’t seem to care what conservatives think about complete repeal of Obamacare, they’re going to be shocked when they count the votes.”

Ryan’s efforts precede Wednesday’s visit by newly confirmed Health and Human Services Secretary Tom Price, who will attend lunch with Senate Republicans, ostensibly to articulate President Donald Trump’s position. In addition, Republicans are pressing Price to do as much as he can through executive actions to buy them time to come to a consensus this spring.

It may take a direct intervention from Trump to get the party's warring factions in line.

“It’s hard to see how this gets done unless the president says, ‘OK, let’s do it this way,’” said Sen. Lamar Alexander (R-Tenn.), a key committee chairman on Obamacare.

But it's been awhile since Republicans have heard something substantive from Trump on Obamacare. When the president last weighed in constructively, he was prompted by Paul's appearance on a cable news show, during which he railed against efforts to repeal the law without a replacement. Trump called up Paul to offer his support.

At first, Trump’s call to repeal and replace simultaneously disrupted the party — which at the time was intent on repealing now and figuring out the rest later. But eventually, they came around to Trump's apparent position and stopped sniping for a few weeks. Now that the party is back in disarray, no one is quite sure what Trump wants. They're straining to read the tea leaves from a president whose latest statements about Obamacare have confused the timeline and offered no clear direction.

“Right now, I would say it's not that easy to repeal it. I don't know if it's a guarantee,” said Rep. Peter King (R-N.Y.). “I don't know where the White House is. The president has said he's not going to be kicking people off the program, off the rolls. He's not going to do that.”

Speaking at the White House alongside Ryan, Trump said simply: “We're working on Obamacare. It will be very soon." That did nothing to clear up the ambiguity.

The main dividing line is between centrist-minded lawmakers urging caution and deliberation — Alexander is a leader of that faction — and conservatives demanding action now.

It appeared that the take-it-slow camp was winning out just last weekend. Republicans increasingly gravitated toward an approach that would stuff as many replacement provisions into a repeal bill as possible, taking advantage of a parliamentary tool that allows them to avoid a Democratic filibuster in the Senate. But that approach takes time — for one, to figure out whether the proposal complies with Senate rules — and the House Freedom Caucus grew antsy.

Now the Freedom Caucus — in tandem with Paul, who's been meeting with the rowdy band of conservatives regularly — are pushing for another vote on a 2015 repeal bill vetoed by President Barack Obama. That was originally the starting point for Republicans after the election. But now, some Republican senators are wary, because there's no guarantee it would be replaced with something satisfactory to millions of their constituents.

The divide has put Republican leaders in a serious jam.

“It’s hard,” said Sen. John McCain (R-Ariz.). “If it were just up to me, I’d have the plan tomorrow.”

Ryan tried to offer a soothing message to Senate Republicans on Tuesday. He laid out a timeline that would have the House GOP start the repeal process by the end of February and pass a bill by the end of March, attendees said. Vice President Mike Pence also attended the meeting but said nothing about Obamacare, senators said.

But Ryan’s reassurances only served to paper over real differences of opinion among Republicans. The party has little room to maneuver, with a narrow 52-48 majority in the Senate and a bloc of Freedom Caucus members in the House that could, in theory, block the GOP’s repeal efforts.

Still, senior House Republicans believe they have the upper hand, if for no other reason than it will be extremely difficult for any GOP member to oppose Obamacare repeal legislation, even if it's not entirely to their liking.

“It’s very hard to vote against repeal of Obamacare in any form, no matter who you are or where you are on the Republican spectrum,” said Rep. Tom Cole (R-Okla.).

If Republicans took the Paul-Freedom Caucus approach, there’s little chance that senators from states that have expanded Medicaid under Obamacare would go for it. The conservatives' plan would allow for two-year transition time away from Medicaid. But 20 GOP senators are from expansion states and they want more time and stability for hundreds of thousands of constituents that rely on Medicaid now for insurance.

‘There are certain aspects of a repeal mechanism that are extremely important to me. And that Medicaid expansion piece is one,” said Sen. Shelley Moore Capito (R-W.Va.).

Although Trump could conceivably whip the competing GOP factions into line, some GOP officials privately say they've been tuning him out. The president's shifting public statements sometimes don't match what aides are saying behind the scenes. Trump has called Ryan to discuss health care on a number of occasions, and Jared Kushner, his son-in-law and senior adviser, has expressed interest in the subject, said several people familiar with the matter.

At one recent meeting, Trump referred questions about Obamacare to Ryan "for the details," according to a person who was present.

At a recent congressional retreat, Andrew Bremberg, a senior policy adviser in the White House, gave remarks to aides and members. But several people who attended the briefing said it was clear the White House didn't have most of the specifics figured out.

GOP leaders may be able to arrive at a bill without Trump. But selling it to congressional Republicans and the public requires a microphone that only Trump has. Congress is about to head home to more town halls filled with constituents who are worried about their health care.

“Statements from the White House about it, frankly, would be helpful,” said Rep. Carlos Curbelo, a moderate Florida Republican.

Republicans said Price's word is as good as Trump's on Obamacare, giving him an important assignment on Wednesday. But when Price addresses Senate Republicans on Wednesday, Paul, for one, won’t be there. He’s scheduled to give a news conference at that time with Freedom Caucus members about his bare-bones Obamacare replacement.