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Story highlights

Moderates and conservatives both want changes to the plan, sometimes at each others' expense

Medicaid among the sticking points

(CNN) —  

House Republicans on both ends of the ideological spectrum are clamoring to be heard by GOP leaders pushing forward on a possible vote on health care legislation next week.

But the reality is that not everyone can get what they want from House Speaker Paul Ryan, who is trying to get the 216 Republicans he needs to vote for the bill without any Democratic support. He can afford to lose 21 members; 20 are on the record leaning against it, according to CNN’s latest count.

And as leaders listen to complains, Ryan and others are already counting votes. The speaker was spotted having a long conversation on the House floor Thursday afternoon with Rep. Gary Palmer, an Alabama Republican opposed to the current bill.

One change that House leaders are considering is adding a work requirement for able-bodied adults who receive Medicaid. The change may appease some conservatives without alienating moderates that leadership needs to hold on to.

One Republican member with direct knowledge of the negotiations said that there is no “arm twisting ” at this point and no decisions have been made yet on how to amend the bill to get it passed on the House floor.

“Anytime you have a large bill like this, it’s a balancing act. I think all sides are going to try to get their issues addressed. I don’t think it’s leaning one way or another,” the Republican said.

The member cited specific concerns they have heard in whip meetings including moving up the Medicaid expansion expiration date, making tax credits more generous based on income level for older Americans as well as adding a work requirement.