Many House Republicans who gambled to pass a healthcare plan must now turn to a new challenge: survival.
The two largest purges of House members since the early 1940s have followed efforts to remake the nation's healthcare system: in 1994, when Democrats lost 52 seats after the collapse of the Clinton administration's healthcare plan, and in 2010, when the party lost 63 seats after the narrow passage of the Affordable Care Act, known as Obamacare.
Those precedents have fed Democratic hopes that efforts to repeal President Obama's healthcare plan could have a positive side effect for them: control of the House in 2018.
Significant uncertainty remains. Democrats would have to gain almost two dozen seats to take back the House. Voters won't cast their ballots for 18 months, a span of time in which other issues could rise in importance. And at least some Republicans believe that experts who failed to predict President Trump's victory last November are failing to understand voter attitudes toward Congress and healthcare today.
But right now, both sides are planning for a midterm election in which the highly contentious and historically emotional issue of healthcare is likely to remain a focus. The fact that the Senate isn't likely to begin debate on its own plan until June, and the two Republican-led chambers will then have try to forge a compromise, means the issue will remain in the headlines for weeks, perhaps months.
Studies of the impact of the 2010 Obamacare vote showed that Democrats from vulnerable districts "paid a significant price," George Washington University political scientist Sara Binder said. (The 1994 healthcare plan was killed without a vote.)
"They were far more likely to lose their seat, even once we factored in everything else that would have affected them in those places," she said of 2010's spurned incumbents.
"There's an analogy here," she said. "It was a risky vote for many Republicans."
Despite the risks, however, Binder and others said that internal party politics made Thursday's vote imperative for the GOP.
"It's hard inside the Beltway to get a good appreciation for how popular Obamacare repeal remains for Republican voters," Binder said. "Republican leaders clearly think they owe their base this vote."
In the end, that argument was the one that persuaded many wavering Republicans to vote for the bill: After the party had promised for seven years to repeal Obamacare, it simply couldn't turn its back on the voters who had accepted that promise and elected them. (A Pew Research poll taken in February showed that almost 9 in 10 Republican voters opposed Obamacare.)
"There's a danger any time politicians change what is perceived as a government mandate," said Harmeet Dhillon, one of two Republican National Committee members from California and a former vice chair of the state GOP. "For Republicans, there was also a danger in doing nothing."
But that doesn't change the fact that voting for the bill also carried huge risk. Already, nonpartisan election handicappers are saying that Thursday's vote put Republicans in competitive congressional districts, including several in California, at greater jeopardy. Seven California Republicans serve in House districts won last November by Hillary Clinton and considered competitive in 2018; all voted for the GOP healthcare plan.
David Wasserman, who analyzes Houses races for the nonpartisan Cook Political Report, said in a report Friday that the post-vote landscape "is consistent with past scenarios that have generated a midterm wave" against the party in power.
"Not only did dozens of Republicans in marginal districts just hitch their names to an unpopular piece of legislation, Democrats just received another valuable candidate recruitment tool," he said. "In fact, Democrats aren't so much recruiting candidates as they are overwhelmed by a deluge of eager newcomers, including doctors and veterans in traditionally red seats who have no political record for the GOP to attack — almost a mirror image of 2010."
Between presidential elections, independent voters generally lose interest. That means midterm races typically become a battle between party regulars. The party out of power — in this case Democrats, who with the loss of the White House in November have no power base in Washington — historically benefits from increased intensity among its disgruntled voters.
That certainly has been true leading to the 2018 elections. Already, Democrats have used as motivation President Trump and his early moves on issues including immigration, his budget plan that would gut many domestic programs, and healthcare.
Special elections in Kansas and Georgia earlier in the spring have suggested that Republican voters, meanwhile, have been less enthusiastic in the early months of the Trump administration.
The question of whether the healthcare vote has immediate political consequences will be tested in upcoming elections prompted by the departures of Republican incumbents for roles in the Trump administration.
In Montana, where voters will decide May 25 on a replacement for Ryan Zinke, the former at-large congressman who is now Interior secretary, Democrat Rob Quist immediately sought to use the healthcare measure against Republican Greg Gianforte.
Quist said the bill "would kick thousands of hardworking Montanans off of their health insurance and raise premiums by hundreds of dollars a month" in addition to lessening protections for those with preexisting conditions.
"No real Montanan would vote for it," he said, castigating his opponent as standing "with the special-interest authors of this bill." Gianforte has supported repealing Obamacare but said Friday he would not have voted on the House measure until congressional budget officials had determined its impact.
Jon Ossoff, the Democratic nominee in the tossup Georgia House runoff on June 20, also used the vote to extend his credibility as an independent voice — a key need in a district that has long been held by Republicans.
The measure that passed the House, he said, "puts Georgians' lives at risk."
"Congress should put aside partisan politics and work to make affordable insurance and quality care available to all Americans," he said.
Once the special elections wrap up, both parties will turn their attention to 2018. At this early point, Democratic strategists say they are thrilled about the potential benefit of the House vote.
The Democratic congressional campaign committee will start airing drive-time radio ads Monday on multiple stations in the Los Angeles market. The ads are aimed at five Republicans representing competitive southern California districts.
"What happened today is devastating for Darrell Issa's reelection bid," Parke Skelton, a strategist for Mike Levin, one of the two Democrats challenging the Vista congressman, said Thursday night.
Levin previewed the argument that many Democrats will make against Republican incumbents: "He voted to have a massive tax reduction for the wealthiest among us, like him, rather than preserve access to affordable healthcare."
(Issa, whose November victory came by the smallest margin of any House race, said that his constituents needed relief from the Obama plan.)
While much will happen between now and election day 2018, Skelton said he is confident healthcare will remain top of mind for voters.
"There's very little Congress can do that people take more personally than monkeying around with healthcare," he said.
Republicans are hopeful that by that time voters will begin to see benefits — either to their health insurance or through the tax cuts that were included in the healthcare measure, assuming those survive the Senate remake.
"It is way early in the cycle," said Republican pollster Ed Goeas when asked for a prediction.
Republican fortunes will rise if voters' focus next year is not on the vote but on "seeing some real differences in their lives," he said.
3:05 p.m.: This article was updated with a comment from Montana Republican Greg Gianforte and plans by the Democratic Congressional Campaign Committee to begin running ads in the Los Angeles market.