Even as congressional Republicans celebrated their latest symbolic jab at the Affordable Care Act, the GOP confronts an increasingly urgent challenge to develop a meaningful alternative in the face of Donald Trump's enduring candidacy.
More than five years after the health law was enacted, the party still has no unifying healthcare platform. And if Trump extends his run atop the Republican presidential field, his unorthodox healthcare positions may soon define the GOP.
Trump, who is increasingly worrying Republican party leaders, has said little on the campaign trail about healthcare beyond bashing the current law and promising that "everybody's going to be taken care of" and "the government's gonna pay for it," as he said on "60 Minutes" in September.
In the past, Trump has expressed admiration for government-run systems in other countries such as Britain and Canada. Such systems are anathema to most conservatives.
"It might be a wise thing now for Republicans in Congress to articulate a well-thought-out plan as, shall we say, a suggestion," said Joe Antos, a longtime health policy expert at the conservative American Enterprise Institute in Washington. "That seems like a sensible thing for a political party to do in these uncertain times."
Although congressional Republicans — and most of the party's presidential contenders — have neglected to develop a healthcare platform, Democratic front-runner Hillary Clinton has rolled out an increasingly detailed agenda that builds on the current law commonly called Obamacare.
Among other things, she wants to expand regulation of insurance companies and drug makers to protect consumers from surprise medical bills and skyrocketing drug prices. More recently, she proposed initiatives to tackle Alzheimer's disease and autism.
Campaigning in Iowa this week, she ridiculed the latest Republican repeal vote.
"Because they have no plan, the Republicans just want to undo what Democrats have fought for decades [to do] and what President Obama got accomplished," she said at a town hall meeting in Davenport on Monday.
The GOP-controlled House sent Obama a repeal bill Wednesday that would rip out major pillars of the health law, including government subsidies to help low- and middle-income Americans buy coverage and federal aid to states to help them expand their Medicaid programs.
That would save the government money but also leave 22 million people without health coverage and drive up insurance premiums, according to an analysis by the nonpartisan Congressional Budget Office.
Obama was expected to quickly veto the bill, which passed the Senate last month.
Republican lawmakers have nonetheless billed their latest effort — by one count the 62nd such bill since 2011 — as an important step, noting that it is the first major repeal bill to make it to the president's desk. Because the legislation was developed through a process known as budget reconciliation, it could not be filibustered by Democrats in the Senate.
The bill, which also would cut federal funding for Planned Parenthood, passed 240 to 181, with one Democrat joining 239 Republicans to back the measure and three Republicans joining 178 Democrats opposing it.
"It is a new year, a new day," House Majority Leader Kevin McCarthy (R-Bakersfield) said Wednesday. "It's going to be a new agenda to make sure America is confident again."
House Speaker Paul D. Ryan (R-Wis.) is promising that this year he will follow up with a substantive healthcare alternative.
"We owe people the right to decide if they want to stay on this path or not, and the only way you can do that is if you offer another path," the new speaker told reporters recently at his Capitol office. "And not just some vague platitudes, get some pollster [to] tell you what to say, but an actual path."
Ryan could draw on an emerging consensus among conservative healthcare experts about how to move away from the Affordable Care Act to a more conservative program for expanding health coverage and controlling costs through broad deregulation and devolution of power to states.
Last month, a group of these experts issued a 70-page blueprint through the American Enterprise Institute that proposes to free health plans from federal mandates that they cover basic benefits — a key requirement of the current law.
The blueprint also proposes a system for providing tax breaks to help Americans who don't get coverage at work, replacing the current law's subsidies for low- and middle-income Americans with a system based on consumers' age.
Most Republicans also favor redesigning the 50-year-old Medicaid safety net that covers about 70 million poor Americans. They would give states block grants and let them revamp their programs.
And the House has already backed a plan by Ryan to convert the Medicare program for the elderly and disabled into a voucher system that provides subsidies to patients to enable them to shop for commercial insurance plans.
But never before have congressional Republicans put all these pieces together into a bill that they could present to the president, in large part because the process is complicated and will require large, often politically unpopular trade-offs.
For example, capping Medicaid expenditures and tying assistance to age rather than income, as many Republicans favor, would almost certainly leave many low- and middle-income Americans with fewer protections.
And rarely do Republicans talk about how they would pay for a system that would preserve the coverage gains made by the Affordable Care Act.
"If Ryan can rally a majority of the House behind serious changes, it would be very helpful," said Gail Wilensky, a centrist Republican who oversaw the Medicare and Medicaid programs under President George H.W. Bush. "The fact is there have not been enough serious alternatives" to the Affordable Care Act.
A House healthcare plan could be particularly useful for a new Republican president like former Florida Gov. Jeb Bush or Sen. Marco Rubio of Florida, who to varying degrees represent the establishment wing of the GOP. Two coauthors of the American Enterprise Institute report are advising Rubio's presidential campaign.
What effect it may have on Trump or even Texas Sen. Ted Cruz of Texas, who is also running something of an insurgent campaign, is less clear.
Wilensky, who has informally advised Bush's campaign, expressed doubt any congressional action would influence Trump.