He's hammering unfunded mandates — disputing the CBO score — and telling forceful anecdotes about his mother-in-law fighting cancer with a drug that is not available in Britian's socialized health care system.
As of now, there are 209 firm "no" votes, 193 firm "yes" votes, and 25 or 26 votes that could go either way. Democrats need 23 of them to pass the bill, but most of those "either ways" are "yes" leaning.
But Ryan is still fighting. Perhaps the typical disregard afforded to Congressional proceedings is not holding true today, and he'll actually get noticed as a new leader on financial issues and constitutional conservatism. I'd like to think that more Americans are paying attention to the House floor than usual.