One hour into Sen. Ted Cruz’s town hall meeting on veterans issues in McKinney, Texas, on Wednesday night, a doctor stood up and told him, “You all are scaring the living daylight out of us with the health care nonsense you’re doing.”

Cruz, who has been a key player in the Senate’s health care negotiations, responded that he is fighting to repeal President Barack Obama’s signature health care law, and working to expand choice and competition to lower insurance premiums. 

“The process of repealing it in Congress, it’s been messy. It’s been bumpy. I am not certain we’ll get it done,” the Texas Republican said, according to a recording of the event. “I hope we will. I believe we will.”

The exchange highlighted broader questions facing Cruz as he looks to repeal the 2010 law, a stance that helped propel him to national prominence. Does he make the bill more conservative, potentially compromising on other aspects of the legislation? Or does he ultimately vote against the bill because it doesn’t go far enough? And what will Texas voters think?

A new ‘constructive’ Cruz?

Five years ago, Cruz looked into a television camera and said the effort to repeal the health care law would be an “epic political fight.”

“There is going to be enormous pressure to compromise,” Cruz said. “I think we should repeal it in its entirety.”

Cruz’s comments came during a televised debate with Texas Lt. Gov. David Dewhurst, who also said he wanted to repeal the law. The pair were locked in a runoff for the Republican nomination for the Senate. They were similar in substance, but differed in style.

Cruz, a well-spoken lawyer who had never been elected to office, pulled off an upset to win the primary, a major tea party victory. 

Fast forward to this summer, and the stridently conservative political outsider is now working on the inside.

Cruz has been engaged with 12 other colleagues in closed-door discussions on the legislation to repeal parts of the health care law. The senator who once spoke of the pressure to compromise is now welcomed by his colleagues for his willingness to do so.

The quieter, behind-the-scenes style is a change for Cruz, according to his fellow lawmakers. Four GOP senators used the same word to describe his role: constructive.

“It is welcomed,” said South Carolina Sen. Lindsey Graham, who was open about the disdain senators felt for Cruz. (Graham once joked that if Cruz was murdered on the Senate floor, a jury of senators would not convict the killer.) Graham and Cruz both ran for the GOP presidential nomination last year, losing to Donald Trump.

“I think running for president was probably a good experience for him,” Graham said. “It shows the diversity of the party and being able to solve problems is a good thing.”

Senators also positively describe Cruz’s willingness to engage in one-on-one meetings. Sen. Rob Portman, who raised concerns about the health care legislation’s effect on Medicaid recipients, said Cruz came by his office last week to discuss the stalled bill.

“He’s been looking for ways to find compromise,” the Ohio Republican said.

For Cruz’s allies, his role in the deal-making is no surprise.

“I’ve known him in private and I’ve known him to be a deal-maker the entire time that I’ve been in Congress,” said North Carolina GOP Rep. Mark Meadows. “Many others in the public have not seen that.”

Meadows, who chairs the hard-line conservative House Freedom Caucus, said Cruz and GOP Sens. Mike Lee of Utah and Rand Paul of Kentucky have been keeping his caucus up-to-date on Senate developments. But the North Carolina Republican said Cruz has been “guarded” when he talks to House members.

“His communications with us have been more strategic and focused than perhaps just saying, ‘Well, let me share what’s going on,’” Meadows said. “It’s almost seen as he doesn’t want to undermine the credibility he has with some of these senators.”

Chip Roy, Cruz’s former chief of staff, now at the Texas Public Policy Foundation, said Cruz hasn’t shifted his style, but is adjusting to a Republican-controlled government.

“He’s trying to reflect and represent the people who sent him to Washington to change it,” Roy said. “What is different is the operating environment.”

Meadows said he didn’t expect too many Cruz supporters to be deterred now that he’s working from the inside.

“For every person that may wish that he took a more strident position, I think there’s at least one, maybe two, that would say we’re glad that Congress is finally making progress,” the congressman said.

Cruz also still has the backing of conservative outside groups, who support his amendment allowing insurance companies to offer plans without certain coverage areas mandated by the 2010 health care law, as long as the companies sell one plan that complies with the mandates.

But his amendment could render the current Senate proposal, known as the Better Care Reconciliation Act, too conservative for the more moderate members of the GOP conference. The bill remains at a standstill, with the risk of nothing getting done to fulfill the promise Republicans have campaigned on for seven years.

If nothing gets done, Republicans, and even Cruz, could face a backlash from voters frustrated by inaction.

“If there’s three votes [against the GOP bill] and he’s one of the three that could be a problem,” said one Texas GOP operative. “I think Obamacare’s that important to the Republican primary voter.”

Others disagreed, since Cruz’s opposition would likely be because the bill did not repeal enough of the health care law.

“The promise is to repeal Obamacare, not to pass anything that has the word health care in it,” Texas Republican Party Chairman James Dickey said.

Democrats see Cruz’s conundrum as a lose-lose situation for him.

“He’s going to have to ultimately vote against this, and have reneged on his years-long pledge to repeal and replace Obamacare,” said Matt Angle, a Texas Democratic consultant. “Or he’s going to vote for and help adopt something that is going to hurt people badly.”

Eyes on 2018

Cruz is one of only eight Republican senators up for re-election in 2018, and he already has a Democratic challenger in Rep. Beto O’Rourke.

“The health care debate couldn’t come at a better time for Beto O’Rourke because of the reliance of many of the red counties in Texas on government-sponsored health care,” said Colin Strother, a Texas Democratic strategist.

Texas is one of 18 states that did not expand Medicaid under the 2010 health care law. But more than 4 million Texans are enrolled in the program, while roughly 3.6 million rely on Medicare, according to the most recent data provided by Texas Health and Human Services and the Kaiser Family Foundation.

Localizing the bill’s impact by explaining how the GOP legislation could affect Texans would be a smart move for O’Rourke, Strother said.

However, Republican voters in the Lone Star State have supported politicians who campaigned on repealing and replacing the 2010 law. Given the state’s conservative leaning, GOP operatives believe Cruz is still in a strong position. Inside Elections with Nathan L. Gonzales rates this race Solid Republican.

Cruz also won last year’s presidential primary in Texas by nearly 17 points. Trump won the state in November by 9 points.

That victory margin for Trump was the smallest for a Republican presidential nominee in Texas in twenty years. One GOP consultant raised concern over historic trends, in which the president’s party does not fare well in the first midterm election of the administration, and said it’s possible GOP voters would stay home.

Democrats say there is a renewed energy around O’Rourke, the young third-term congressman from El Paso. Republicans say O’Rourke, who supports a single-payer health care system, is too liberal for Texas. But Democrats think he could have a chance.

“Smart people are going to be wary that a Democrat can win in Texas right up until they do,” said Strother, the Democratic strategist. “I think that’s kind of a natural state.”

“To have someone run as a bold progressive that says, ‘I’m not ashamed of who I am or what I believe in,’ that’s a different dynamic that we haven’t seen statewide in Texas,” Strother said. “And I happen to think it’s something that we can’t handicap for.”

As O’Rourke travels the state taking on Cruz from the left, Republicans are not gearing up for a primary battle. Dickey, the party chairman, said he was not aware of any primary challenges to Cruz, and said the party does not take sides in primaries.

GOP Rep. Michael McCaul last year declined to say whether he would challenge Cruz. Asked last week if he was considering a primary challenge, McCaul said, “I don’t want to talk about Ted Cruz.”

McCaul criticized Cruz for focusing on his national ambitions instead of serving the Lone Star State, a criticism some Texans say the senator still faces today. In 2018, Cruz is looking to prove that he’s laser-focused on Texas.

“I think Sen. Cruz realizes that he took on some negative water from the presidential race and he’s trying to move past and show people that he’s focused on his job,” one Texas GOP operative said. “It’s very clear that he’s going to be in the Senate for while.”