Evan Vucci / AP

The American Health Care Act has now passed through three committees on its way to a vote on the House floor. So far, the Republican leadership’s replacement for Obamacare has emerged unscathed, and unchanged.

It is not likely to stay that way much longer.

Conservatives say they have the votes to defeat the measure, and they plan to introduce an amendment that would push it significantly to the right, likely by ending the Affordable Care Act’s Medicaid expansion earlier than 2020 and by allowing states to institute work requirements for recipients.

Their bid to change the bill will force Speaker Paul Ryan to make a critical decision: Accept a significant amendment that could mollify the right at the expense of party moderates, or risk an embarrassing defeat on the floor of the House that would smash the GOP’s top legislative priority.

Increasingly, it seems the choice is being forced on the speaker. As of last week, Ryan had told reporters that Republicans in the House and Senate faced a “binary choice” on the health-care bill, resisting all but the most minor tweaks to the legislation. That position came under fire immediately, first from conservatives who quickly called his bluff, then from Republicans who warned House leaders that their bill wouldn’t come close to the 51 votes it needs to pass the Senate. Ryan got little help from President Trump, who repeatedly told conservative lawmakers and activists during White House meetings that the bill was open to negotiation.

Asked on Wednesday by Tucker Carlson if the House bill was “the best Republicans could do” after seven years of promising to repeal and replace Obamacare, the president replied: “I think there’s going to be negotiations.” At another point in the interview, Trump appeared to concede that the bill could hurt the working-class voters that supported him. “If we’re not going to take care of the people, I’m not signing anything,” he said.

By Wednesday night, Ryan had already begun to bend. But how much?

The party would make “necessary refinements and improvements” to the bill, Ryan told reporters at an evening press conference. On Thursday morning, though, he was careful to note that it would not be subject to a wholesale rewrite. “Clearly,” Ryan said at a Capitol press conference, “the main parts of this bill are going to stay exactly as they are.” If he was frustrated by the president’s mixed signals about the bill, he wasn’t showing it. Ryan repeatedly praised Trump’s involvement, saying he was making it “easier” to pass health-care reform and comparing his communication skills to those of Ronald Reagan. The show of support appeared to be a rebuttal to conservative Trump allies who have accused Ryan of misleading the president about opposition to the health-care legislation. On Wednesday he said Senator Rand Paul was “insulting” Trump by suggesting the speaker had sold him “a bill of goods.”

In part, the speaker’s new willingness to accept changes is due to a tactical shift. Republican leaders had initially hoped to pass their bill through both the House and Senate in the span of a few weeks, but opposition from key senators has ruined those plans. Because the GOP must use the budget reconciliation process to get the bill through the Senate with only a simple majority, it must be subject to amendments. And Ryan indicated on Thursday he now expects a much more drawn-out negotiation that will require a House-Senate conference committee, potentially delaying a final bill—if they can reach agreement at all—by weeks if not months.

The upshot is that the speaker isn’t worried much about the Senate at the moment. “My job is to move bills through the House,” Ryan said Thursday. “I am not the Senate majority leader.”

Conservatives dominate in the House far more than in the Senate, and so Ryan must try to win over many of the three dozen or so members of the House Freedom Caucus who have balked at the leadership’s bill. Three of them became the first Republicans to vote against the proposal in the Budget Committee; the bill advanced narrowly on a 19-17 vote. Procedurally, the panel could not make substantive changes to the legislation, but its Republican members agreed to requests from conservatives to issue recommendations to tighten Medicaid eligibility and end new enrollments sooner than 2020.

Whether those changes would be enough to win over the right is unclear. Representatives Jim Jordan of Ohio and Raúl Labrador of Idaho, both members of the Freedom Caucus, said they would unveil their own amendment in the coming days. They have criticized numerous aspects of the bill, including its refundable tax credits, its Medicaid language, and a provision that would require people to pay a premium to insurers if they go without coverage for more than two months. Party leaders could accept their amendment when the Rules Committee meets next week, or they could draft their own changes in an effort to secure conservative support. The changes most likely to be made are those targeting Medicaid.

Yet while Labrador said on Thursday the bill could be fixed, he strongly criticized Ryan’s performance and said he should take lessons from Nancy Pelosi, the former Democratic speaker who steered the Affordable Care Act to passage seven years ago. “I do think at some point the leadership needs to figure out how to keep the promises we made to our constituents,” Labrador said at a conservative panel event. He also mocked efforts by the leadership-backing American Action Network to urge his constituents to pressure him to support the repeal bill. “Every person has called to oppose the bill,” Labrador said.

By reopening the legislation, Ryan must bring on enough conservatives without losing the votes of more moderate Republicans who represent states that expanded Medicaid or have older and more vulnerable populations. Representatives Ileana Ros-Lehtinen of Florida, Rob Wittman of Virginia, and Leonard Lance of New Jersey have announced their opposition to the bill after the Congressional Budget Office determined it would cause 24 million people to lose insurance coverage over the next decade. Others, including Representatives Peter King of New York, Charlie Dent of Pennsylvania, and Tom MacArthur of New Jersey, have said the continuation of Medicaid at least until 2020 is important to them. The leadership, which still hopes to hold a floor vote next week, can suffer 21 Republican defections while still reaching the 216 needed for passage.

Ryan has said the goal now is to identify “the sweet spot” that can get the GOP’s long-promised repeal-and-replace bill out of the House and into the Senate. What’s clear from the past few days is he hasn’t found it yet.

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