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Republicans have 2 ways forward on health care reform. Both look bleak.

Paul Ryan, House GOP Address Press After Republican Party Conference Photo by Mark Wilson/Getty Images

Four days after House Republicans failed to get enough votes to pass an Obamacare replacement plan, Speaker Paul Ryan (R-WI) said that they are working hard to unify the Republican party — without revealing when Republicans plan to take on health care reform again.

“We had a very constructive meeting with our members, some of those who were in the ‘no’ camp expressed a willingness to work on getting to ‘yes’ and to making this work,” he told the press Tuesday. “I’m not going to put a timeline on it because this is too important to not get right.”

House leadership’s sudden decision to put the brakes on health care to “get it right” is a welcomed change for the most conservative faction of the party, which spent the past three weeks decrying Ryan for attempting to ram through the ultimately unsuccessful American Health Care Act.

AHCA’s failure proved to be a wake-up call for congressional Republicans. It was the first major legislating swing-and-a-miss for the Republican Party after gaining control of the House, Senate, and White House — and it was on a promise GOP members have been campaigning on for more than seven years.

Conservatives, many of whom crucially came out against the ACHA in its final days, don’t want to see Obamacare continue as the law of the land: “Pulling the plug on Obamacare after 17 days doesn’t make any sense — Republicans have been talking about how awful Obamacare is since 2009,” said Dan Holler, the vice president of Heritage Action, a conservative advocacy group that campaigned against AHCA.

If Republicans are really serious about making good on their promise to “fix” Obamacare, they have essentially two choices: unify Republicans (a strategy that ultimately resulted in the failure of ACHA) on a repeal-and-replace plan, or try to work on something bipartisan to fix the existing law. Both seem like a huge challenge right now.

While Democrats have said they are willing to work with Republicans on health care, a new Republican strategy of playing to the party’s moderates is the exact opposite of what conservative groups and lawmakers were hoping for — and would likely render them the opposition to yet another repeal and replace bill.

Conservatives think Obamacare can be replaced with only Republican votes

On Friday afternoon, the basement of the Capitol Building flooded with frustrated House Republicans who had just been informed the American Health Care Act was “dead,” as Rep. Greg Walden (R-OR) put it.

In some regard, Ryan’s decision to pull the bill from the floor was a win for conservatives, in that they had actively campaign against its passage. But it wasn’t a “victory,” Heritage Action Vice President Dan Holler said. It simply bought time to push for full repeal and replace of Obamacare.

The next step for conservatives is finding common ground, Club for Growth spokesperson Doug Sachtleben said.

“It’s a question of who leadership is going to cater to,” Sachtleben said. “Instead of catering to one faction over the other, you have got to look at this to say, what is it that we campaigned on, what did we tell voters we are going to do. Let’s do that.”

But so far, Republicans haven’t proven that’s in the realm of possibility. After a week of negotiations with both the conservative Freedom Caucus and moderate Tuesday Group, the Republican Party couldn’t agree on a plan to replace Obamacare. Even having successfully moved the bill far more to the right, Rep. Mark Meadows, (R-NC) and more than a dozen of his fellow conservative Freedom Caucus members still said they couldn’t get on board — and their amendments lost even more votes among the moderate Tuesday Group Republicans.

“I wonder with some of my colleagues, whether they wrote the bill themselves, whether they could get to yes,” said Rep. Bill Huizenga, (R-MI) who was in favor of the bill.

Club for Growth, Heritage Action, and Freedom Caucus lawmakers have argued that repealing Obamacare’s regulatory provisions and adding in the ability to buy insurance across state lines would have won over conservatives to pass the bill.

Of course, everyone can agree they ideally would like to lower premiums and ensure more affordable and accessible coverage for all, but House leadership has been wary of these changes, claiming they go against Senate rules. This is a huge hurdle for the repeal-and-replace strategy, since new legislation requires 60 votes rather than budgetary measures, which only require a simple majority.

Even under budget reconciliation, there is debate among Republicans whether or not these deregulatory provisions would be able to make it past a Senate parliamentarian. Conservatives just don’t seem to care.

Turning to Democrats on health care would split the Republican Party even more

In that regard, conservatives’ ideal legislation is looking less and less likely. Already House leadership and the White House have hinted any future changes to health care would not be done through budget reconciliation — meaning they need a filibuster-proof majority Senate.

To accomplish that, Republicans need at least eight Democrats on their side to get new legislation to Trump’s desk. However impossible sounding, it’s increasingly becoming one of the most viable routes for the upper chamber of Congress.

"It's clear it needs to be done on a bipartisan basis," Sen. John Cornyn, (R-TX) told reporters Tuesday.

But it’s caused a lot of frustration in the House, Ryan said, especially since the loudest opposition to the American Health Care Act came from the right-wing faction of the party.

“The reality is that if the president and congressional republicans want to accomplish what they campaigned on, they are not going to find willing partners in Democrats,” Holler said.

Democrats have said they are willing to work with Republicans on health care reform. On Tuesday, Rep. Nancy Pelosi (D-CA) sent a letter to the Democratic conference asking for ideas to improve the Affordable Care Act.

As long as premiums go down, everyone is insured, and provisions like defunding Planned Parenthood are not included, they’re in, Democratic Whip Rep. Steny Hoyer (D-MD) said on Friday.

“If their objective is to make sure Americans have quality health care, we are prepared to work with them. If President Trump sends down to the Congress of the United States a bill that provides insurance for everybody, at a lower cost and higher quality, I will vote for it,” Hoyer said, repeating an Obama-ism from just after the election.

Hoyer, like Obama did, is making a gamble. Democrats think Obamacare is the most politically viable piece of legislation to accomplish all those things — and they’re betting Republicans won’t have better ideas.