But it's not just Trump who is delivering mixed messages on health care. Congressional Republicans, who over the past six years have constructed a political identity tied largely to their hatred of Obamacare, seem to be surrendering the fight.

An important symbol of the GOP's changing tune came last week, when members of both parties on the U.S. Senate Committee on Health, Labor, Education and Pensions approved a bill authorizing $162 billion in discretionary spending for the U.S. Department of Health and Human Services and a number of other major federal agencies. It was the type of appropriations bill that used to be relatively noncontroversial, but in recent years, have been held up by partisan rancor.

Although it maintains a strict limit on funding for the "risk corridor" program that helps ACA insurers offset losses, the bill that passed committee and is expected to pass the Senate and House does not dismantle or defund the health law. Rather than wage another grueling and ultimately futile fight over a policy that will not change as long as President Obama is in office, Senate Republicans cooperated with Democrats on the bill to boost funding for the National Institutes of Health by $2 billion and to increase spending on the prevention and treatment of opioid addiction.

Sen. Ted Cruz (R-Texas) helped lead a shutdown of the federal government in 2013 over funding the Patient Protection and Affordable Care Act. (Photo: J. Scott Applewhite/AP Photo)

From shutdown to deal-making

Few political observers would have predicted that the party leadership credited with provoking the 2013 government shutdown over the funding of the ACA would be the same ones making deals on health care legislation with Democrats during the heart of an election year.

Similarly, House Republicans are discussing bills that would make a number of small changes to the ACA, such as changing the documentation requirements for enrolling in marketplace plans or redefining how insurers can use the age of a policyholder to set premiums.

The House bills being discussed, which are generally aimed at allowing insurers to charge more for plans, are largely opposed by Democrats and may not get through a filibuster by the minority party the Senate. But they nevertheless represent a more realistic effort to craft health policy than the GOP's previous insistence on a complete repeal of the ACA. 

Rep. Gene Green (D-Tex.) told The Hill that he plans to oppose the bills, which he said put the interests of insurers before those of people, but he appreciated the apparent change in strategy from the majority party.

"I've been asking for that for about six years," he says, regarding potential changes to the ACA. "Let's go back and fix it, because any bill Congress ever passed, typically we wait a year or two, see how it works, we go back in and fix the problems. We haven't had that opportunity because it's always just repeal."

And yet, the official GOP party line is still "repeal." But Speaker Paul Ryan is trying to make the repeal effort a more cerebral exercise. A task force of Republicans assembled by Ryan is expected to unveil a comprehensive repeal and replace plan later this month. If it's everything Ryan promises, it will amount to the first time GOP leadership has actually proposed a meaningful alternative to the ACA.

In crafting a replacement for the ACA, Ryan and other Republicans must confront the fact that 24 million Americans have gained health coverage as a result of the law. Throwing those people off insurance would not only harm the individuals economically, but would likely embitter them against the GOP for the long term, something Ryan no doubt wants to avoid.

But while Republicans may be able to come up with a bill that anticipates the problems caused by repealing the ACA, it is nearly impossible for them to anticipate the response from Trump.

Ryan, who withheld an endorsement of his party's presumptive nominee for several weeks over professed concerns about Trump's commitment to party values, very likely asked the billionaire to align his positions on health care with those that Congressional Republicans will try to advance. But whether Trump will abide by Ryan's request — or even remember it — is anybody's guess.