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Sen. Rand Paul, R-Ky., walks to a room on Capitol Hill in Washington, Thursday, March 2, where he charges House Republicans are keeping their Obamacare repeal and replace legislation under lock and key. J. Scott Applewhite / AP

"Obamacare is dishonest in that it says, 'Yeah, we can expand it, but it won't cost anything,'" Sen. Rand Paul (R-KY), an early critic of the GOP bill, told NBC News. "Our country has a $20 trillion debt. It's a huge burden that I think threatens the country from within."

More moderate Republicans, however, are worried about reducing funding or changing the program too rapidly.

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There are some complaints on the House side as well. "I remain concerned about the impact of the Medicaid changes on vulnerable populations, as well as the overall effect of the bill on access to affordable care," Rep. Charlie Dent (R-PA), who represents a swing district, told NBC News in a statement.

While few members have declared their outright opposition to the bill, there's no obvious way to satisfy one side's concern without further alienating the other. That could make for a difficult negotiation as the party struggles with additional divisions over issues like tax credits for private insurance and whether to defund Planned Parenthood.

Some 32 states, including the District of Columbia, have accepted the ACA's increase in federal aid and many of the expansion states have Republican governors and state legislatures. Powerful advocacy groups representing doctors (

The controversy boils down to simple math. Under the House bill, states would have to make major cuts and raise taxes or simply drop coverage and benefits for the groups covered under the ACA. The Center on Budget and Policy priorities estimates that the House GOP plan would

This helps explain why Republican governors have been some of

As Kasich and other Republicans have mentioned, there are specific concerns tied to the opioid epidemic governors are confronting around the country and that President Donald Trump referenced often on the campaign trail. Medicaid pays for rehab and mental health treatment for many victims of drug abuse. In addition to removing millions from the program by undoing the expansion, some policy experts warn that the House's fixed per-capita formula would make it harder for states to respond to unexpected crises like drug outbreaks that raise the average cost of treating individual patients.

Caving in to the demands of moderate Republicans becomes even more complicated for another reason: The 19 states that have so far declined to participate in the Medicaid expansion.

These states paid a considerable price for their decision to stand with conservative activists demanding they hold the line against Obamacare with a future repeal bill in mind. A gap in the law created by the Supreme Court's Medicaid ruling left many poorer residents with incomes too high to qualify for Medicaid but too not high enough to qualify for subsidies to buy private insurance. The ACA also cut funding to hospitals for uninsured patients that the Medicaid expansion was supposed to make up.

The House bill makes some money available to non-expansion states elsewhere to try and address these fairness concerns, but any moves to bring more moderate senators into the fold in the expansion states could upset this balance.

"If a state expanded their Medicaid they should not somehow get a benefit from having done so versus a state that did what I thought was responsible at great political cost," Sen. Marco Rubio (R-FL), whose governor turned down the expansion, told NBC News.

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Why Medicaid Is So Hard for Republicans - NBCNews.com