House Republicans, despite stiff political headwinds, are readying an ambitious push this week to begin moving legislation to replace major parts of the Affordable Care Act, a crucial test of their ability to fulfill one of their party's main campaign promises.
The plan marks the first time GOP lawmakers will do this since Obamacare was enacted seven years ago and will provide an early indication of whether President Trump can rally his party's members of Congress, many of whom are anxious about how to repeal and replace the healthcare law.
The legislation could affect health insurance for tens of millions of Americans — not only those with Obamacare coverage, but also people with employer-provided insurance and Medicaid.
The House legislation — which was being finalized over the weekend, according to GOP officials — aims to fundamentally restructure the system that Obamacare created, which has extended health coverage to more than 20 million previously uninsured Americans.
GOP plans call for scrapping insurance marketplaces that require insurers to offer a basic set of benefits and that provide government subsidies to help low- and moderate-income Americans who don't get health benefits at work to buy health plans.
Republican legislation would lift many requirements for benefits that plans must cover. And it would create a new system of subsidies that are linked to consumers' age, rather than their income, according to leaked drafts. That would make insurance harder to buy for millions of Americans, especially low-income working people, outside analyses suggest.
GOP leaders would eliminate taxes that have helped offset the cost of Obamacare's coverage expansion, including taxes on medical device makers and insurance companies and on households making more than $250,000 a year.
Instead, Republicans are proposing to tax the health insurance that employers provide their workers. Employer-provided benefits are currently tax-free. The change could cause the price of insurance that many Americans get on the job to go up.
The House plan would phase out hundreds of billions of dollars in federal aid that has allowed many states to expand their Medicaid programs to millions more poor Americans.
House Republicans also want to give states more flexibility to reshape their Medicaid programs, allowing states to potentially limit benefits or require poor patients to pay more for their medical care.
The GOP plan would eliminate Obamacare's unpopular insurance mandate, which requires Americans to have health insurance or pay a penalty.
In its place, House Republicans have proposed to allow insurers to charge higher premiums to Americans who let their insurance lapse.
Most of these proposals are deeply controversial, even within Republican ranks. That is a big reason why Republicans have not previously moved forward with a plan to replace Obamacare.
"There is not a consensus at this point," Sen. Susan Collins (R-Maine) said Sunday on CBS News' "Face the Nation."
White House officials and senior GOP lawmakers nevertheless are sounding upbeat.
"We're putting the finishing touches on our plan," Vice President Mike Pence said in Wisconsin on Friday on a trip with Health and Human Services Secretary Tom Price to visit House Speaker Paul Ryan (R-Wis.) in his district.
And House Ways and Means Committee chairman Kevin Brady (R-Texas), whose committee could hold a hearing on proposed legislation as soon as this week, said he's confident the president is behind the House plan. "There was no mistaking he is exactly on the same page as House Republicans," Brady said.
Ryan and Senate Majority Leader Mitch McConnell (R-Ky.) have suggested Congress could send President Trump legislation as soon as this month, even though Republican leaders as of Sunday had still not released the text of their healthcare legislation.
While the Republican-led Congress did pass a bill to repeal large parts of Obamacare, which President Obama vetoed last year, this marks the first time the party will offer a replacement bill and subject it to the scrutiny of congressional hearings and the legislative process.
But the GOP faces mounting opposition from major advocacy groups representing patients, doctors, hospitals and now even businesses, a traditional Republican ally.
At the same time, internal GOP divisions threaten to derail the legislative campaign before it even gets off the ground.
Leading conservatives in the House and Senate have said they will oppose any legislation that does not fully repeal Obamacare, while many Republican senators and governors representing states with major coverage gains have voiced serious reservations about rolling back too much of the existing law.
Conservatives have criticized the House GOP plan as "Obamacare-lite," accusing party leaders of replacing one tax-funded government entitlement with another.
"They're going to have a new tax, a new government subsidy program and a new [insurance] mandate," charged Sen. Rand Paul (R-Ky.), who has rallied against the plan with the conservative House Freedom Caucus and influential outside groups such as Heritage Action and the Club for Growth.
"Speaker Ryan and Leader McConnell need to stand up to those in the Republican Party who are fighting to retain and repair Obamacare, rather than repeal and replace it," said David McIntosh, president of the free market advocacy group Club for Growth, which is known for backing primary election challenges to wayward Republicans.
Together, the conservatives have the votes to potentially tank the House GOP plan because to pass any healthcare legislation, Republican leaders cannot afford to lose more than 18 votes in the House.
"Their margins, especially in the Senate, but also in the House, are thin," warned National Retail Federation vice president Neil Trautwein, a former aid to McConnell.
"They have a better chance of getting this out of the House, but it's not automatic, even though they are taking draconian steps to get their caucus in line. … And what they are doing with this secrecy and locked rooms isn't helping."
House Republican leaders came under fire last week for only allowing committee members to view drafts of proposed healthcare legislation in a first-floor room of the Capitol that was off limits to Democrats and even Senate Republicans.
Many advocacy organizations are urging House Republicans to slow down and allow more time for independent assessments of the legislation.
To date, the independent Congressional Budget Office, which lawmakers rely on to calculate the effect of proposed bills, has not released an estimate of how much Republicans' plans would cost and how many people could lose health coverage.
"Making substantial changes to our healthcare system by changing current law would impact tens of millions of our patients," Dr. Nitin S. Damle, president of the American College of Physicians, said in a letter to House committee leaders last week.
"Congress therefore must avoid any unintended adverse consequences," the letter said, calling for "an open and transparent legislative process."
Under the current GOP plan, the House Energy and Commerce and Ways and Means committees are expected to hold hearings on different pieces of the legislation as soon as this week.
That could allow the full House to vote on an Obamacare repeal bill by as early as the end of the month and send it to the Senate, where a much longer debate is expected.
John Desser, a former health official in the George W. Bush administration and former aide to Sen. John McCain (R-Ariz.), predicted Ryan would rally his caucus and get the 218 votes he'll need.
"The speaker has lived and breathed health policy for over two decades, and may just be perfectly positioned … to bring together his conference and explain the opportunity they have to get this right to reluctant or recalcitrant members," he said.
But Desser, now a vice president for eHealth, an online insurance marketplace, cautioned that other challenges await.
"Getting it through the Senate after that may require the gravity-defying leadership of Mr. Trump and his team," he said.