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Story highlights

Ryan is attempting to pass a top Republican agenda item -- repealing Obamacare -- through the House

Moderate and conservative members are unhappy with the legislation

The stakes are the highest ever for Ryan

(CNN) —  

The future is now for Paul Ryan.

In the pandemonium of the health care fight, the House speaker’s reputation, authority and political fate are on the line in a way they never have been before during his charmed assent to the pinnacle of Washington power.

During Ryan’s Wednesday blitz of cable news and talk radio shows to shore up the bill, CNN’s Jake Tapper greeted the speaker with George Washington’s line to Alexander Hamilton in the musical “Hamilton” – “winning was easy, young man, governing is harder.”

A battle-worn Ryan replied: “I have been using that quote a lot lately.”

The new reality is an unusual state of mind for someone who made few enemies on the way up and mastered the crucial trick of never looking to grab for power, as he cultivated a reputation as conservative intellectual and disciple of Reagan-era budget hawk Jack Kemp, happier with budget blueprints than in the spotlight.

Ryan shot into the conservative stratosphere by sparring in a televised summit with a young President Barack Obama on health care. He escaped Mitt Romney’s losing presidential campaign in 2012 without a scratch, using a spot as vice presidential nominee to polish his brand as a rising Republican star.

Then he glided into the speaker’s chair with little effort as the only feasible unity candidate. The Catholic boy from Wisconsin swallowed distaste for President Donald Trump’s morals for a shot at a GOP monopoly in Washington and an era of generational conservative reform.

But Ryan’s trademark wonkery, charts, data and optimism will not be enough to get the job done this time. Now he must wield power, risk making enemies, drive bargains and deploy the political muscle to get his troops behind a bill.

The face of the House’s “American Health Care Act,” Ryan is in an uncomfortable position as the bill tips into trouble and risks taking his leadership authority, Republican unity and Trump’s fledgling presidency down with it.

The measure is being assailed by moderates scared by a rollback of a Medicaid expansion and a Congressional Budget Office study suggesting it could deprive 24 million people of insurance. Conservatives, ignoring Ryan’s reality of having to pass a repeal bill through a budget mechanism known as reconciliation that limits its scope, think it essentially retains Obamacare intact.

Thus far, nobody’s happy. A Fox News poll released Wednesday found that only 34% of Americans backed the plan.

According to a CNN whip count, 19 GOP House members now oppose or are leaning against it. Ryan cannot lose more than 21. The speaker could not guarantee to Tapper that it would survive a final vote if it came up right now.

“It’s not coming up this afternoon. It’s going through the legislative process. That legislative process has not been finalized. So that’s kind of a, no offense, kind of a goofy question or faulty premise,” Ryan said.

Should he succeed in getting a bill out of the House and eventually onto Trump’s desk, Ryan can expect to be a bona fide hero to traditional conservatives and to find a way into the hearts of even the most committed anti-establishment Trump voters by delivering a desperately needed early win to the President.

At this point, it is difficult to tell whether Ryan’s bill is simply caught in the kind of political maelstrom and skittishness of wavering House members faced with tough votes that afflicts all major legislation or whether Washington is watching a political project locked in terminal decline.

The cost of failure is clear

Not passing a bill to repeal Obamacare would be a cataclysm for Ryan and his party and risk alienating grassroots voters who have sent gradually increasing majorities to Washington to get it done.

Florida freshman Republican Rep. Francis Rooney, who is supportive of the leadership’s approach on Obamacare, told CNN that it would be “damaging for all of us if this fails.”

“We’ve been given this Lazarus moment to rise from the ashes and change the direction of the country,” Rooney said, ticking off the major items Republicans vowed they would tackle like health care reform, foreign policy and tax reform.

“If we fail on the first one out, I think it really sets our conference back and the President back,” he added.

Ryan is not there yet. But he risks falling into the same kind of limbo that neutered his predecessor as House speaker, John Boehner, whose agenda was constantly impaired by the nihilistic tendencies of his own caucus.

The impact of failure, meanwhile, on Ryan’s personal political prospects would be hard to underestimate – after all, alongside Trump, he would be jointly responsible for the biggest Republican legislative blowout in decades.

Under fire from Republicans and conservative media

Kentucky Sen. Rand Paul, who believes Ryan’s bill – which swaps Obamacare subsidies for tax credits – does not go far enough and would not halt rising premiums. He slammed the speaker’s management of the bill.

“I think that Paul Ryan’s selling him a bill of goods that he didn’t explain to the President, and the grassroots doesn’t want what Paul Ryan is selling,” Paul said.

On Tuesday, conservative talk show host Laura Ingraham suggested Ryan was leading the President on a perilous path.

“I think Donald Trump is going to get caught on this in 2020,” Ingraham said. “I think there’s a trap set for him on this. I’d like to spend an hour talking to him about it. I think this is a trap set for Trump and it’s going to be bad.”

Breitbart vs. Paul Ryan: Website publishes audio of Speaker trashing Trump

And in recent days, Ryan has come under scorching fire from Trump’s allies in the conservative media. Earlier this week, Breitbart News – the outlet formerly run by Trump political adviser Stephen Bannon – released a tape recorded during the presidential campaign of him telling Republican lawmakers he would not defend Trump’s behavior.

Breitbart writer Matthew Boyle accused Ryan of convincing Trump that his bill would repeal Obamacare when it wouldn’t.

“This is the first major initiative that Trump has worked on with Ryan – and the fact it is going so poorly calls into question whether Speaker Ryan, the GOP’s failed 2012 vice presidential nominee who barely supported Trump at all in 2016, really understands how Trump won and how to win in general,” Boyle wrote.

It was not the first, or the last, Breitbart slam against Ryan.

One story said that Ryan’s hold on the speakership was being eroded by roadblocks facing the health care bill. Another said that his approval rating in his own district was lower than Trump’s because of his “Obamacare 2.0” bill.

Questions about the speaker’s relationship with the White House also mounted this week when officials made clear Trump was ready to change the repeal bill – after Ryan has insisted the measure in its present form was the only way to repeal Obamacare.

Trump’s friend Christopher Ruddy wrote in a Newsmax column on Tuesday that the President should ditch what he called “Ryan Plan II.”

He warned that the current approach “doesn’t fulfill Trump’s own vision of universal health care while removing the onerous requirements of Obamacare.”

Ryan insists that all this is just noise and says he and the White House are in lockstep.

“Those websites have been attacking me from day one. I’m used to this sort of thing. This is what you deal with in this job,” Ryan said.

“That is not where the Trump White House is. We’re working hand in glove with the White House. We meet with him constantly, daily. We’ve worked on this bill together. The President is all in on this,” Ryan told Tapper.

How to maintain goodwill

It’s also the case that Ryan remains popular among his caucus – much more so than Boehner was after his fractious years in power – so he has political capital to spend on the health care bill.

Even members of the Freedom Caucus, the conservative members who believe his bill does not go far enough, have been unwilling to personalize their disappointment about the bill into a wider critique of the speaker.

But to retain the goodwill and support, Ryan must find a way to thread the repeal bill through the House in a form that can be palatable to the Senate, including more moderate Republicans who balk at his approach.

It could hardly be more complicated. Ryan seems to understand that the hopes of ushering in an era of conservative governance – and his own and his party’s future – rest with the decisions he will make in the coming days.

“As the governing party, we have a responsibility to do big things,” he said on Capitol Hill on Wednesday. “As the governing party, we have to tackle the big issues that are facing the country before they tackle us.”

CNN’s Deirdre Walsh and Lauren Fox contributed to this report.