WASHINGTON – Efforts of congressional Republicans to reach consensus on how to replace the Affordable Care Act got more complicated Wednesday.

A block of House conservatives backed a proposal by Sen. Rand Paul, R-Ky., putting into question whether Congress will preserve the expansion of Medicaid that insured millions more people under President Barack Obama’s signature health care law.

At a press conference, Rep. Mark Meadows, R-N.C., chairman of the conservative House Freedom Caucus, said “conservatives are coalescing” around Paul’s plan to replace the law known as Obamacare.

Freedom Caucus members who want to get going on a repeal see his bill as moving the ball forward.

House Speaker Paul Ryan and Rep. Greg Walden, R-Ore., chairman of the Energy and Commerce Committee, said they are working on proposals to repeal the law deliberately.

“Health care is very important to all Americans. We want to get it right, and we’ve been taking our time to do that,” Walden said.

In contrast, Meadows said Paul’s plan, sponsored in the House by Rep. Mark Sanford, R-S.C., is ready to go.

It’s a “definitive plan that addresses many of the concerns my constituents and constituents around the country have raised,” Meadows said.

Paul said Republican promises to repeal the controversial law were a big reason for the party’s Senate gains in 2014 and again last year.

“We owe it to conservatives to repeal,” he said at the press conference.

Their plan includes several ideas popular with conservatives. As Paul and Meadows envision it, the House will repeal all of the Affordable Care Act including a requirement that all Americans have insurance, expansion of Medicaid, and subsidies for those buying insurance on state-level marketplaces.

None of those provisions is included in Paul’s replacement plan.

Paul said dropping the requirement on what insurers must cover will lower the cost of insurance. “This legalizes the sale of affordable insurance,” he said.

Sanford said the plan “maximizes individual liberty and freedom,” and government will not be “deciding what is essential” to cover.

Their replacement plan calls for individual tax credits up to $5,000. It also would allow Americans to put more into health savings accounts, up to $5,000 per year.

It does not replace Medicaid expansion that has insured about 10 million people in states that chose to take federal money to cover people who previously made too much to qualify for the benefit.

A number of Republican senators from states that expanded Medicaid, including West Virginia Sen. Shelley Moore Capito,  have aired concerns about endangering those who’ve benefited. 

Capito, who is co-sponsoring a separate bill to give states the option of deciding issues like whether to preserve expanded Medicaid, said in a statement Thursday that she’s “committed to ensuring that there is a stable transition when Obamacare is repealed.”

Capito also said she wants to “avoid any gaps in coverage and ensure those currently covered by the Medicaid expansion are protected and retain access to health care.”

One key player, Rep. Brett Guthrie, R-Ky., said in a statement that he will review Paul and Sanford’s proposal.

But Guthrie, vice chairman of the House health subcommittee, said he believes Medicaid expansion is “unsustainable” and is “developing Medicaid reform legislation that will protect the most vulnerable in a sustainable way.”

Meadows acknowledged that a safety net may be needed for those insured by the expansion, but the Freedom Caucus wants to eliminate the program.

Additionally, not all Americans would benefit from the health care tax credit.

An outline of a plan released by Ryan included a proposal for a health insurance tax subsidy. Meadows said the Freedom Caucus opposes the idea of a subsidy, and a tax credit only benefits those who make enough money to pay taxes.

Increasing how much money can be put into health savings accounts only helps those with enough disposable income to take advantage of the tax-exempt accounts, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

Eliminating a requirement that insurers cover such things as maternity care would return the market to the way it operated before the Affordable Care Act, said Pollitz, adding that it was hard to find plans that covered maternity care.

Dropping parameters for what plans cover also eliminates a requirement for coverage of contraceptives, which conservatives have opposed.

Meadows said health care savings accounts could be used to buy contraceptives – an arrangement that conservatives can accept because they won’t be subsidizing it through their premiums.

Kery Murakami is the Washington, D.C. reporter for CNHI’s newspapers and websites. Contact him at kmurakami@cnhi.com.