WASHINGTON (KTVU/AP) -- Cheering and clapping, House Republicans and President Donald Trump congratulated each other on passing a Republican American Health Care Act (AHCA) through the House Thursday.
"This has brought the Republican party together. We are going to get this finished," said a triumphant President Trump.
"Make no mistake, this is a repeal and a replace of Obamacare, make no mistake about it," Trump declared. "Premiums will be coming down, deductibles will be coming down."
The celebration in the White House Rose Garden pushed Republicans one step closer to delivering on seven years of campaign promises to dismantle the Obama Affordable Care Act (ACA) health care law.
But the bill passed by a narrow 217 to 213 victory, that resulted in not a single Democrat voting for the bill. They were joined by 20 Republicans who also voted no. Many of those were moderates who are concerned about provisions in the Republican bill that would eliminate the ACA Medicaid expansion and allow insurers to charge people more for pre-existing health conditions.
"Many of them are in districts that were won by Hillary Clinton," said political analyst Brian Sobel.
Democrats countered that the GOP bill would have the opposite effect from what Trump predicted, pointing to estimates it will mean 24 million more people will be uninsured, while imperiling coverage for people with pre-existing conditions who had gained protections under Barack Obama's Affordable Care Act.
"These things are incredibly detailed, technical documents that need a lot of explanation. And it's hard for even the members to know what they're voting on much less constituents back in the district. So it becomes kind of a public relations war," said Sobel.
Republicans control the House, Senate and the White House, but in President Trump's first 100 days, it became clear the real health care battle is not with Democrats, but between factions within the Republican party itself.
Conservatives want a complete repeal of Obama's health care law, while swing-state moderates want to retain Medicaid expansion and preserve some parts of the Affordable Care Act.
"You will glow in the dark on this one," House Minority Leader Nancy Pelosi dramatically warned, predicting the GOP health bill will be toxic to Republicans in the 2018 midterm elections.
Some Democrats taunted Republicans with chants of a classic rock song "nah, nah, nah, nah, hey, hey, goodbye" -- an echo of how protesters serenaded Democrats seven years ago when they passed Obama's bill.
The House bill will now be sent over to the Senate, where Republicans hold 52 seats. That means, in order to reach a simple majority vote, Republicans cannot afford to lose moderates on one end of the ideological spectrum, or conservatives from the other.
"I don't think that the House bill necessarily predicts what is in the Senate bill, and we have only 52 senators, there has to be consensus," said Republican Rep. Bill Cassidy of Louisiana.
"That may mean everything from eviscerating the bill to taking the bill as it came out of the House and working with pieces of it," said Sobel.
Senate majority leader Mitch McConnell (R-Kentucky) already began the process Thursday morning, by convening a small group of Republican Senators to start formulating priorities.
The House GOP health bill would eliminate the fines Obama's law imposed on people who don't buy coverage, and erase tax increases in the Affordable Care Act on higher-earning people and the health industry. It would cut the Medicaid program for low-income people and let states impose work requirements on Medicaid recipients. It would transform Obama's subsidies for millions buying insurance, now based largely on their incomes, making the funding skimpier and tying it to consumers' ages.
And states could get federal waivers freeing insurers from other Obama coverage requirements. With waivers, insurers could charge people with pre-existing illnesses far higher rates than healthy customers, boost prices for older people to whatever they wish, and ignore a mandate that they cover specified services like pregnancy care.
The bill would block federal payments to Planned Parenthood for a year, considered a triumph by many anti-abortion Republicans.
The Congressional Budget Office estimated in March that the GOP bill would end coverage for 24 million people over a decade. The House voted without a CBO estimate for the latest version of their bill.
Although it's focused mostly on the minority of Americans who buy health coverage in the individual market, the GOP bill could also significantly impact the many who are covered by large employer plans. In one little-noted provision, employer plans could take advantage of state flexibility under the legislation to pick and choose which states' rules to live by. That could allow them to impose annual and lifetime coverage limits, which are prohibited under Obamacare, and get rid of certain annual out-of-pocket spending caps.
Protesters were on hand again for Thursday's vote, shouting "Shame on you! Shame on you!" and "2018! 2018!" as Republicans boarded buses outside the Capitol to head to the White House.
Yet as the 2016 election amply demonstrated, political outcomes can be difficult to predict. Republicans argued they would have had a still heavier price to pay if they failed to make good on an endlessly repeated pledge that helped them seize control of the House, the Senate and the White House in the years since the law passed.
Back in 2010, the Democrats held Congress and the White House and used their majorities to jam through an unpopular health care law on a partisan basis, just as Republicans have done now.
As lawmakers prepared to vote, House Speaker Paul Ryan told them: "Many of you have been waiting seven years to cast this vote. Many of you are here because you pledged to cast this vote."
"They expect us to govern -- if we're going to be around," Republican Rep. Dennis Ross of Florida said of voters.
The White House had pushed hard for a vote, and Trump got personally involved in last-minute maneuvering. He helped bring wavering moderates on board after a deal secured by conservatives last week scared them off by limiting protections for people with pre-existing conditions. The final change, agreed to just Wednesday at the White House, was to add $8 billion over five years to help people with pre-existing conditions, a sum critics called a relative pittance.
Indeed, despite assurances by GOP leaders that their legislation would rescue a failing health care system, it was opposed by nearly all medical and consumer groups, from the American Medical Association to AARP. The Chamber of Commerce supported the bill.
The health legislation passed the House on a banner day for Republicans on Capitol Hill, as the Senate gave final congressional approval to a bipartisan $1.1 trillion spending bill to keep the government running through September, and a House committee approved legislation that would gut the Democratic-authored Dodd-Frank law that regulated Wall Street after the 2008 financial crisis.