Congressional Republicans renewed their assault Thursday on the Affordable Care Act, as the House passed legislation to redefine the law's definition of full-time work, a key detail that would affect how employers must provide health benefits to workers.
But Republican leaders are still grappling with how to use their new congressional majorities to fulfill the party's long-standing pledge to roll back what they call Obamacare.
The prospects for a Senate vote on the work-hours bill are unclear. And the party is still crafting a strategy to replace the sweeping healthcare law, nearly five years after President Obama signed it.
"This will require some skillful political maneuvering," said Gail Wilensky, who headed the Medicare and Medicaid programs under President George H.W. Bush and helped Sen. John McCain (R-Ariz.) develop a healthcare plan during his 2008 presidential campaign.
"There are no perfect plans.... And everything requires trade-offs," she added, noting that if Republicans want to provide health coverage to low- and middle-income Americans, as Obama's healthcare law does, they will need to find some way to pay for it.
The law has already expanded health coverage to about 10 million previously uninsured Americans, surveys show. Senior Republicans have not indicated what would happen to these people if their party succeeds in overturning the law.
Some now say any major action will have to wait until later this year, after the Supreme Court decides the latest legal challenge to the law.
If backed by the court, the challenge — called King vs. Burwell — would take away tax subsidies that millions of Americans rely on to get health insurance through the law. That lawsuit would probably affect residents of 36 states that rely on the federal government to operate their insurance marketplaces.
"It is the one thing that will force the president's hand — that will force the president to negotiate with Republicans on a transition and a replacement," said Sen. John Barrasso (R-Wyo.), chairman of the Senate Republican Policy Committee and one of a group of senior party lawmakers who are working on alternatives to the healthcare law.
With Republicans in control of both the House and Senate for the first time in eight years, expectations are running high among critics of the law that the party could begin seriously taking it apart.
Some Republicans, including Texas Sen. Ted Cruz, have demanded a new all-out repeal effort.
And leading conservative pundits, including Bill Kristol, editor of the Weekly Standard, have urged Republicans not to do anything that could improve the law.
Party leaders are laboring to temper expectations. Without a veto-proof majority, Republicans stand little chance of enacting a full repeal.
Sen. John Cornyn of Texas, the No. 2 Senate Republican, this week told CQ Roll Call, a Washington publication that follows Congress, that party lawmakers should hold off on a new repeal effort until they demonstrate they "can actually get some things done."
Sen. Lamar Alexander (R-Tenn.), the new chairman of the Senate Health Committee, urged more-targeted efforts to change the law.
"We should start by repealing the medical device tax, restoring the definition of a work week to 40 hours, allowing people to buy insurance across state lines, and ensuring that more American families can keep the health insurance plans they like," he said.
But even redefining full-time work may prove challenging.
The healthcare law is designed to require employers with more than 50 full-time employees to provide health benefits or pay a penalty. Full-time work is defined in the law as more than 30 hours a week.
Business groups, who have urged that full-time work be defined as 40 hours a week, say the lower threshold has encouraged employers to keep down workers' hours. That argument has been bolstered by anecdotes from around the country, although government statistics show no major shift to part-time work in recent years.
"Restoring the 40-hour work week would benefit retail employees with more income and encourage more full-time employment," the National Retail Federation said in a letter to House leaders this week.
But many more Americans work a 40-hour week than a 30- to 34-hour week, data show. That has prompted warnings that raising the threshold could mean even more workers would be shifted to part-time work.
At the same time, an independent analysis of the proposal from the Congressional Budget Office concluded that raising the threshold would balloon the federal deficit by more than $50 billion over the next decade.
According to the budget office, the bill also would lead to 1 million fewer people getting health benefits at work and would increase the number of uninsured Americans and the number getting insurance through government programs such as Medicaid.
The bill passed the House 252 to 172, with 12 Democrats joining Republicans to back the measure.
The White House has indicated the president will veto the legislation if it makes it to his desk.