The Republican-led Congress passed a plan Friday to start the process of repealing the Affordable Care Act, but the road ahead remains unclear.
House Republicans approved the budget blueprint, 227-198, following a similar party-line vote earlier this week in the Senate, which sets a month-end timetable to draft a repeal bill. But leaders warned the process could take longer.
The week was full of theatrics as Republicans struggled to fulfill one of their major campaign promises. One by one, Republicans rose at their desks to criticize Obamacare — Rep. Drew Ferguson (R-Ga.) compared the ACA to a goat ransacking the interior of a house. "I have to get the goat out," he said.
And after each GOP speech, Democrats reminded lawmakers of how many hundreds of thousands of Americans might lose their healthcare coverage in that lawmaker's state if Obamacare is repealed — more than 580,000, for example, in Georgia.
But launching the repeal process was the easy part. Republicans aren't any closer to fulfilling their longtime promise to "repeal and replace Obamacare," even though they will now control the House, Senate and White House.
President-elect Donald Trump said this week that he expects Congress to act swiftly, promising that a plan will be coming as soon as his pick for Health and Human Services secretary, Rep. Tom Price (R-Ga.), is confirmed for the Cabinet.
"It'll be repeal and replace. It will be essentially, simultaneously," Trump said. "It will be various segments, you understand, but will most likely be on the same day or the same week, but probably, the same day, could be the same hour."
Republican leaders, though, know that is a promise easier made than kept.
Ever since President Obama signed the healthcare bill into law in 2010, Republicans have been unable to coalesce around a viable option. Friday's vote showed the trouble ahead as nine Republicans, a mix of the most conservative and most moderate, declined to back the first step.
"We're not holding hard deadlines, only because we want to get it right," said House Speaker Paul D. Ryan (R-Wis.). He has committed to having repeal and replace done "this year."
But without a clear path forward, rank-and-file GOP lawmakers are becoming increasingly nervous that constituents back home will lose their healthcare coverage if the ACA is repealed before a replacement is enacted.
In closed-door meetings over the past two weeks, Republicans have expressed much "hand-wringing," as one lawmaker put it. One congressman quoted scripture in asking colleagues to ensure they had a sturdy foundation before pressing ahead with the repeal.
"We do have members who feel if we don't do them together, the replacement plan will never happen," acknowledged Rep. Chris Collins (R-N.Y.), an early Trump supporter. "People will, I hope, fall in line with our new president, make sure we are supportive of him coming right out of the gate."
As voting was underway this week, Republican aides were increasingly suggesting another course of action.
They say the Obamacare replacement will not be a single bill, but a series of actions — some made through regulatory changes by Price at Health and Human Services, others by Trump's executive actions, and some in legislation — to build a new healthcare system.
That process could drag throughout 2017, with many of the changes not expected to be phased in for several years to ease the transition.
"We're not going to swap one 2,700-page monstrosity for another," Ryan said, referring to the Obamacare law.
Republicans have promised their plan will lower the consumer costs of health insurance premiums and deductibles, and give people more choices in choosing coverage. They have floated ideas for expanding tax-exempt health savings accounts and giving lower-income Americans refundable tax credits toward buying their own coverage. They want to end the mandate that all Americans have insurance.
But without legislation, those ideas remain only works in progress.
Meanwhile, more than 20 million people are now benefiting from Obamacare, either by purchasing private insurance on the ACA exchanges or receiving health coverage through the Medicaid expansion. Many people receive government subsidies to defray the costs.
Repealing Obamacare threatens to wipe out that system without providing a new one.
"Why don't they have a remedy?" said Rep. Maxine Waters (D-Los Angeles). "They're not going to have anything better than the ACA."
Approval of the budget package Friday sends instructions to various congressional committees to draft legislation to repeal Obamacare by Jan. 27. But aides cautioned that deadline is not binding, and may slip.
Republicans have approved countless bills to repeal Obamacare before, but their off-the-shelf model needs some fine-tuning now that it has a chance under Trump to become law, they said.
Both Ryan and Senate Majority Leader Mitch McConnell (R-Ky.) hope some of the replacement elements can be tucked into the repeal bill, providing a safety net as they dismantle Obamacare.
But because the repeal bill is part of the budget process, it must hew to budgetary provisions, which throws into question some of the most popular parts of Obamacare — such as allowing young people to remain on parents plans until they are 26 years old or prohibiting insurance companies from denying coverage for those with preexisting conditions.
Meanwhile, lawmakers are wedged between constituents who want them to keep their promise to gut Obamacare, and those worried about what will happen to their healthcare coverage if they do.
"Everyone's getting calls," said Rep. Scott Perry (R-Pa.). "Some people feel a little uncomfortable."