Paul Ryan doesn’t want to work with Democrats on health care. They’re running out of options.

Republicans have two ways to move forward on health care reform, and House Speaker Paul Ryan and President Donald Trump can’t seem to agree on which one to go with.

Ryan shot down Trump’s idea of working with Democrats to push through health care reform in an interview with CBS, which aired Thursday. "I don't want that to happen," he said, referring to the president’s claim that the “the Democrats will make a deal” with him after Obamacare spirals out.

The other option seems just as tricky: attempting to unify House Republicans behind the American Health Care Act. The bill, which died last week before coming to a vote, was caught between two factions of the Republican Party — the conservatives in the Freedom Caucus and the Republican Study Committee, who found it to be too close to Obamacare, and the party moderates concerned with loss of coverage.

Ryan is siding with conservatives — and the GOP-unification case — by arguing the party’s differences are more about politics than policy. "I don’t want government running health care,” he said. “The government shouldn’t tell you what you must do with your life, with your health care."

Conservatives want to try to unify the party again — but it’s not clear they are getting much traction

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. Rep. Chris Collins (R-NY) told reporters that the moderate Tuesday Group agreed Wednesday that they would not meet or work with Freedom Caucus members. "If that call comes in, just hang up," Collins said.

Meanwhile, Freedom Caucus Chair Rep. Mark Meadows (R-NC) said he is still in negotiations with members, but did not confirm any conversations with the Tuesday Group. Meadows added that he had not spoken with Trump since the bill was pulled from the floor Friday.

Last week, negotiations with both the Freedom Caucus and the Tuesday Group hit a dead end. Even having successfully moved the bill far more to the right, Meadows 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, [if] they wrote the bill themselves, whether they could get to yes,” said Rep. Bill Huizenga (R-MI), who was in favor of the bill.

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

What’s clear is what conservatives don’t want: a bipartisan effort to pass health care reform.

“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. Ryan seems to agree.

But the White House has hinted any future changes to health care would not be done through budget reconciliation — meaning they would 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.

Sen. Bob Corker (R-TN) chided Ryan for standing firm with conservatives. “We have come a long way in our country when the speaker of one party urges a president NOT to work with the other party to solve a problem,” he tweeted after Ryan’s CBS interview aired.

Some Democrats have said they are willing to work with Republicans on health care reform. On Tuesday, House Minority Leader 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, Democrats are in, Minority Whip 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 Obamaism from just after the election.

Hoyer, like Obama, 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. At least not ones they can agree on.

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