An array of conservative lawmakers, organizations and activists are demanding a swifter and more aggressive remake of the Affordable Care Act than many Republicans are comfortable with, raising questions about whether President Trump and the GOP are headed toward gridlock as they try to fulfill their promise to repeal the health-care law.

Three conservative senators known for bucking GOP leadership during Barack Obama’s presidency — Ted Cruz (Tex.), Rand Paul (Ky.) and Mike Lee (Utah) — are raising the possibility of doing the same under Trump.

And outside Congress, three prominent groups — Freedom­Works, Americans for Prosperity and Heritage Action for America — plan to increase pressure on lawmakers to repeal the law fully or risk retribution from the conservative grass roots.

If they hold together in the Senate, where Republicans have just 52 seats, the three senators alone could sink a Republican bill.

The current proposal, floated privately this week by House Republicans, repeals portions of the ACA but, because of pressure from constituents who depend on the law, leaves some elements intact that conservatives are not happy about. Few details of the proposal have emerged publicly.

(The Washington Post)

“The repeal bill ought to be a repeal,” Paul said Thursday, decrying a replacement plan House Republicans presented to GOP senators at a closed-door meeting the previous afternoon. He also raised the possibility that Cruz and Lee might join him in voting against it. “Talk to the two people that tweeted out with me,” he said.

[House leaders forge ahead with health bills, hoping to bulldoze internal strife]

Cruz and Lee used similar language in tweets this week. With reporters, Cruz has been more circumspect, but he has left open the possibility of opposing the Republican plan. “There’s agreement and disagreement between the two chambers, but at the end of the day, I believe we will repeal Obamacare,” he said.

In addition to starting a game of chicken with Republican leaders on the Hill and the Trump administration, opponents of anything less than full repeal have also created uncertainty for millions of Americans who receive coverage through the ACA.

The strife came as House Speaker Paul D. Ryan (R-Wis.) laid out a three-week timeline for the passage of health-care legislation in a closed-door meeting with fellow Republicans Thursday, according to numerous attendees.

For the many Republicans who were elected during Obama’s presidency with a mandate to block his agenda, obstruction comes much more naturally than governance. The effort to repeal the ACA is the first major test of whether they can harness the energy they used to oppose the law to actually undo it — or whether ideological divisions will sink the effort.

The coordinated resistance has raised the specter of a resurgent ideological right wing, which has appeared at least publicly to be in retreat since Trump’s victory. Many of the president’s positions, including his desire to protect insurance coverage for Americans, run counter to conservative orthodoxy and leave room for a revolt.

(The Washington Post)

But Trump’s continued popularity on the right puts these conservatives in a tough spot. should the president more fully embrace the emerging House plan. They risk alienating Trump’s loyal base — a prospect many lawmakers do not take lightly.

“I don’t want to draw a line and say that I’m against this proposal and I will put a ‘no’ vote up,” said Rep. Steve King (R-Iowa), who prefers full repeal.

The House plan calls for a refundable tax credit to help Americans afford insurance premiums, but conservatives in the House and the Senate think it amounts to an expensive new federal entitlement.

Key House committees are set to take up legislation as soon as next week. The first steps involve parallel action by the Ways and Means Committee and the Energy and Commerce Committee.

The following week, the House Budget Committee is scheduled to combine the bills into a “reconciliation” package eligible for Senate debate, with votes on the House floor expected the week after that.

No legislative text has been released by Ryan’s office or by the relevant committees. One part of the legislation, handled by the Energy and Commerce Committee, has been made available to members of that panel — but only for inspection behind closed doors.

Paul complained Thursday that House GOP leaders were being too secretive. Democrats voiced similar complaints.

“We’re here today because I’d like to read the Obamacare bill,” Paul said near the room where the bill was being reviewed. “If you’d recall, when Obamacare was passed in 2009 and 2010, Nancy Pelosi said, ‘You’ll know what’s in it after you pass it.’ The Republican Party shouldn’t act in the same way.”

Paul, Cruz and Lee are not the only ones who oppose some details of the House plan. Some House conservatives, including King, don’t like what they have seen and have embraced alternative ideas.

[Trump’s words stir up intraparty feud over tax credits for health-care costs]

Conservative Republicans have long opposed refundable tax credits because Americans with lower incomes, who pay less in taxes, receive the full credit even if it exceeds their tax bill. Nonrefundable credits can be used only to offset actual tax liability — but would also mean less money in the pockets of Americans who need help paying for health insurance.

As a result of that dispute and others, conservatives have slowly built support for a “full repeal” plan since the start of the year. Paul provided the only Republican “no” vote on January’s nonbinding budget reconciliation instructions, saying that it would add too much to the national debt; at the time, Lee and Cruz co-signed a letter saying they would oppose a later bill if it did not repeal the ACA.

Conservatives hailed the apparent unity of Paul, Lee and Cruz on pushing for a full repeal — a model based on legislation that passed Congress in 2015 only to be vetoed by Obama.

“If people don’t credibly think there are 51 votes for a plan, then the plan doesn’t go forward,” said Michael Needham, chief executive of Heritage Action for America, speaking of the Senate. “It’s very helpful to have this bloc in the Senate, and in the House, saying they’re not going to take less than they got in 2015.”

At a Heritage Foundation-sponsored roundtable event with House Freedom Caucus members, Lee said that a repeal bill “should not be anything less aggressive than what we were able to pass in 2015.”

To many Republicans, the current conflict triggers the feeling of deja vu. The House Freedom Caucus had issued threats to oppose Republican budgets and to unseat John A. Boehner (R-Ohio) as House speaker; Cruz had floated the idea of a government shutdown over Planned Parenthood funding and then backed off.

In interviews, opponents of the current House proposal, which they call “Obamacare-lite,” argued that this fight is different. “This has been baking for seven years,” said Rep. Mark Sanford (R-S.C.), a Freedom Caucus member. Fights in previous years “didn’t have the political urgency that repeal does.”

Cruz held forth with reporters outside the Senate chamber for 10 minutes earlier this week, seeming to relish in the chance to criticize the House leadership’s guidelines and pitch an alternative.

“If we fail to honor our commitment to repeal Obamacare, I believe the consequences would be quite rightly catastrophic,” Cruz warned in the same apocalyptic tone he often he used as a presidential candidate.

Cheered by that kind of rhetoric, and planning their own push for full repeal, conservative groups have promised to wage a public campaign against Republicans who buckle and save parts of the ACA.

“We’re going to be more strongly reminding Republicans of their promises made over the last eight years on the issue of stopping — or at least rolling back, anyway — government-run health care,” said Tim Phillips, the president of Americans for Prosperity. “We’re telling them to keep their promises — and they’ve promised an unequivocal repeal of Obamacare.”

Founded by the billionaire donor David Koch, Americans for Prosperity has become an effective grass-roots organization, stopping Republican legislators in Florida, Tennessee and Virginia from expanding Medicaid under the provision of the ACA or building health insurance exchanges. The group, Phillips said, would demand that lawmakers pass full repeal “both in Washington in a very vocal way” and “also back home in their districts.” He declined to be more specific.

Adam Brandon, the president of FreedomWorks, said the group is organizing a “day of action” on March 15, with activists flooding Capitol Hill to “put the heat” on Republicans who don’t support full repeal. They take it as a given that the Cruz-Lee-Paul troika will be with them.

“They’re damn serious,” he said. “It’s completely possible that the Ryan-Trump plan, when there is a plan, gets dropped. My jaw kind of hits the floor when I think that we’re even having a conversation about this.”

On the other hand, some Republicans think they can whittle down the conservative opposition as the chance of repealing the ACA, in part or entirely, becomes more real. Sen. Bill Cassidy (La.), the sponsor of a bill that would allow states to keep most of the ACA if they want to, told reporters this week that Republicans could fulfill their promises if they repealed the most controversial parts of the law.

Cassidy said the mission of Republicans in Congress is not to pitch their ideal plans but to get right with what the president ran on.

“The American people voted for his vision,” he said. “More than any other single person in our country right now, he is in sync with the national mood. If folks want to go their own way, maybe they should run for president.”

As the reporters assembled around, Cassidy began to laugh.

“Maybe they did,” he said.

Kelsey Snell contributed to this report.

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