House Speaker Paul Ryan appeared last week to promote the American Health Care Act. (J. Scott Applewhite/AP)

House Speaker Paul D. Ryan is not backing away from the sweeping health legislation that some opponents are deriding as “Ryancare.”

The Wisconsin Republican has become the salesman in chief for the plan to repeal and replace the 2010 Affordable Care Act, putting a heavy focus on conservative-leaning outlets to try to quell the brewing rebellion on the right flank. On Wednesday morning, he made the pitch on Fox Business Network, his fourth appearance on the constellation of networks owned by Rupert Murdoch in the past week. Then he called in to Laura Ingraham’s radio show and told one of his biggest critics that the plan would be a major conservative victory over the existing law.

“We’re replacing it with Republican tax policy that’s been long-standing stuff that the Heritage Foundation, American Enterprise Institute have been talking for years. It’s the Tom Price bill that most conservatives co-sponsored here just last year,” Ryan told Ingraham, who has built her career opposing most of what Republican leaders in Congress support.

Price, a former House Budget Committee chairman, also has been selling the legislation in his new capacity as secretary of health and human services, along with Vice President Pence and, occasionally on Twitter, President Trump.

But Ryan has been the public face of the sales pitch.

(Peter Stevenson/The Washington Post)

This appears to be a risky bet for the speaker’s political standing because of the mounting concerns on opposite ends of the ideological spectrum of House and Senate Republicans. Far-right conservatives have returned to their Obama-era roots of opposing whatever comes out of the speaker’s office, while moderates from states that expanded Medicaid under President Barack Obama’s Affordable Care Act complain that the initial legislation would take away insurance coverage from millions of people.

That problem is more pronounced in the Senate, where Majority Leader Mitch McConnell (R-Ky.) has less margin for error. That has led some rank-and-file Republicans to complain that Ryan is poised to make the same mistake that Democrats made in 1993 and 2009 on energy policy.

Both of those years, at the start of new administrations, House Democrats pushed through liberal legislation that would not receive even a perfunctory vote in the Senate, stranding dozens of House Democrats without any political cover for having voted for a controversial bill that never became law.

Some Senate Republicans are telling their House counterparts that’s where they are headed — and they are warning them to do nothing instead.

“If you don’t believe it’s better than Obamacare over the long haul, if you think you’re going to own it for the rest of your life, President Trump, it will be called Trumpcare, don’t buy it,” Sen. Lindsey O. Graham (R-S.C.) told conservative radio host Hugh Hewitt on Wednesday.

Graham argued for just letting the existing ACA markets collapse, hoping that would provide the political momentum for more far-reaching legislation that even some Democrats would support, given the urgency. Sen. Tom Cotton (R-Ark.) has called for the House to slow its pace to try to pass the legislation late next week, saying it’s doomed in the Senate and suggesting instead that the proper course is a much more deliberative approach over many more months.

However, there’s a large, silent majority of House Republicans who have made the opposite political calculation. Because so many Republicans represent deeply conservative districts, their biggest fear is an opponent in the primary and not a Democrat in the general election.

This big contingent of House Republicans takes the leadership at its word that this is the best chance to truly repeal what they call Obamacare, House GOP advisers said. They want to vote for anything that does just that and want to support legislation that the Trump administration is backing, even if it dies in the Senate, because that’s easier to explain to angry conservative voters back home who want to know why they didn’t support Trump’s push to repeal the ACA.

Senior advisers in both chambers remain optimistic that the House can still get its version of the legislation over to the Senate — and from there, the Senate might have to amend the Medicaid provisions and set up a House-Senate conference to fight over the differences in the two bills for several more weeks.

In the House, Ryan’s leadership team sees the two pockets of resistance. First, there’s the block of moderates and mainstream conservatives from states that accepted Medicaid expansion to cover some of the uninsured. While they do not seek as much media attention, these wavering moderates far outnumber the conservatives who are currently opposed.

In New York alone, nine Republicans are concerned that the legislation would not do enough to help their constituents who would lose Medicaid coverage and would prefer more generous tax credits to help them buy new insurance plans.

But conservatives are wary of the tax credits, and any expansion of them risks widening the pool of opponents on the right.

That’s why some Ryan insiders are saying that, despite all the talk about modifying the legislation, this bill has been carefully crafted with those two pockets of opposition in mind. Some minor tweaks can be made when the House Rules Committee considers the legislation later this month, but in general, Ryan’s team thinks that any big shift to the right on tax credits or Medicaid would lose too many votes from the center.

Despite the bigger concern about members from those states with Medicaid concerns, Ryan’s public posture has been about demonstrating his conservative bona fides in supporting the bill.

A Wednesday afternoon appearance on CNN’s “The Lead with Jake Tapper” marked Ryan’s 10th one-on-one interview with a national TV or radio personality in a week. Of those interviews, eight have been with conservative-friendly outlets.

“As a governing party, we have an obligation to keep our promises, to pass the reforms that we told people we would pass if we got this opportunity,” Ryan said Monday evening on Fox News Channel’s “The First 100 Days With Martha MacCallum.”

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