Watch Rand Paul to understand why Obamacare repeal is in so much trouble.

Paul faces a more agonizing dilemma than almost any other Republican senator. A libertarian ideologue and Tea Party stalwart, Paul has spoken vociferously about the imperative of repeal for years.

Yet Paul also represents a state that has done well out of the Affordable Care Act. Four hundred and forty thousand Kentuckians have gained coverage under the ACA; Kentucky’s uninsured rate tumbled from 20 percent in 2013 to 7.5 percent in 2015.

Even more strikingly, it is Kentucky’s Appalachian Southeast that has seen the biggest gains from the ACA. And it so happens that southeastern Kentucky voted more staunchly for Paul’s 2016 reelection than did any other section of the state.

Paul won 76.6 percent of the vote in Clay County, where 15.6 percent of the total population has gained coverage via the ACA’s Medicaid expansion. He won 81.5 percent of the vote in Jackson County, where 15.1 percent owe their Medicaid to the ACA. He won 84 percent in Leslie County, where 18 percent would lose Medicaid if Obamacare were repealed.

Very understandably, the version of Obamacare repeal that Senator Paul introduced in January 2017 leaves Medicaid untouched. But, of course, Paul has no such assurance about the version of reform being incubated by the House Republicans under Speaker Paul Ryan. Which may explain why Paul has emerged as the most outspoken Republican critic of Ryan’s health-care approach.