Washington (CNN) In a major victory for President Donald Trump, the House has voted to dismantle the pillars of the Affordable Care Act and make sweeping changes to the nation's health care system.

The bill now heads to the Senate where it faces daunting challenges because of the same ideological splits between conservative and moderate Republicans that nearly killed it in the House.

Trump said he is confident the bill will pass the Senate, calling Obamacare "essentially dead."

"This is a great plan. I actually think it will get even better. This is a repeal and replace of Obamacare. Make no mistake about it," Trump said at a celebratory White House appearance with House Republicans.

After a dramatic week of negotiations, lobbying from Trump and Republican leaders, the vote ended with 217 GOP lawmakers backing the measure. Twenty Republicans opposed it, as did all House Democrats.

Trump argued the health care process has unified the GOP. "We've developed a bond," he said. "This has really brought the Republican Party together."

"As far as I'm concerned, your premiums are going to come down," Trump said.

Democrats were unable to stop the GOP vote aimed at President Barack Obama's signature legislative achievement. But after the final vote was cast, they chanted "nah nah nah nah hey hey hey goodbye" to their Republican colleagues, with a few members waving, as they believe the vote will lead to many GOP lawmakers losing their seats in the November 2018 midterms.

Thursday marks a political milestone -- one that has painfully eluded Trump and House leaders for months. The controversial health care bill delivered Trump the biggest political defeat of his short presidency in March, when the legislation had to be yanked from the House floor because it simply didn't have enough support.

Under pressure from an antsy Trump looking to score a big political victory, Republican leaders tried again last week, hoping to to get to 216 votes ahead of the President's symbolically important 100-day mark in office. That effort, too, failed.

Before the vote on the House floor, House Speaker Paul Ryan made the case that Republicans had no choice but to work to put Obamacare -- what he called a "failing law" -- behind them. "Let's give people more choices and more control over their care."

"Let's return power from Washington to the states," Ryan said.

"A lot of us have been waiting seven years to cast this vote." Ryan said. Many lawmakers, he added are "here because they promised to cast this vote."

'Rocky' plays in GOP meeting

Thursday morning, Republicans were already in a celebratory mode. The theme song to "Rocky" played as members filed in to a meeting in the House basement.

Rep. Daniel Webster described Ryan as almost "giddy."

Asked if he will be relieved when all of this is over, Virginia Rep. Dave Brat said simply: "Highly!"

When it came time for House Majority Leader Kevin McCarthy to speak in the meeting, an image of Gen. George S. Patton popped up on the LCD screens in the room. McCarthy proceeded to roll off several motivational quotes from Patton to urge the conference along.

There was also high praise for Trump: New York Rep. Chris Collins credited the President for getting the bill across the finish line. "This was Donald J. Trump, the negotiator getting it done," Collins said.

Before the final vote, the House unanimously passed a separate bill that will ensure members of Congress and their staffs are subject to the rules of their new health care measure. Originally, Republicans were under fire after it was reported that they wouldn't be subject to the rules of their own bill. Republicans said that they were required to include the exemption under Senate rules.

Democrats ready for 2018 fight

Democrats, for their part, are poised to hold the health care bill over the heads of Republicans next year.

As anxious reporters stood outside of Ryan's office Wednesday night, waiting for guidance on whether there would be a vote Thursday morning, Democratic Rep. Elijah Cummings approached the group to joke that he had a "breaking" announcement.

Republicans had the votes on their health care bill, Cummings said. His punchline: And Democrats will take back the House in 2018.

As originally introduced, the GOP bill would leave 24 million fewer people insured by 2026 than under Obamacare, the non-partisan Congressional Budget Office said. There will not be a new CBO report before Thursday's vote on the legislation.

House Minority Leader Nancy Pelosi blasted the bill and timing of the vote.

"Do you believe in what is in this bill?" she said Thursday. "Some of you have said ... well, they'll fix it in the Senate. But you have every provision of this bill tattoos on your forehead you will glow in the dark on this one."

The remark was met with cheers and applause.

"You will glow in the dark," she repeated. "So don't walk the plank."

But the weight of the moment -- Republicans being able to start the process of replacing Obamacare -- was not lost on Democrats.

Off of the House floor, Democratic Rep. Emanuel Cleaver raised his left pant leg to show a CNN reporter huge scars he has on his knee. He said he has had six surgeries, two to replace his knee.

"I'm thinking about the people back home who are hurting. I'm talking about myself. I mean, I'm a pre-existing condition," he said. "It's not apolitical game for all these people out here in the country who are hurting and scared to death."

Cleaver said when Obamacare was enacted in 2010, he never could have imagined that this day would come.

"I thought that even though this place has become toxic, that nobody would jeopardize the health of millions of people for some political purpose," he said. "And the number is still 24 million people who will be without health coverage."

What's in the bill?

The GOP health care bill would eliminate Obamacare taxes on the wealthy, insurers and others, and get rid of the individual mandate imposed by Obamacare, officially known as the Affordable Care Act. Instead of the Obamacare subsidies that are tied to income and premiums, the GOP plan would provide Americans with refundable tax credits based mainly on age to purchase health insurance.

The legislation would also allow insurers to charge higher premiums to those in their 50s and early 60s, compared to younger consumers.

It would also significantly curtail federal support for Medicaid and allow states to require able-bodied adults to work. After 2020, states that expanded Medicaid would no longer receive enhanced federal funding to cover low-income adults, and those that hadn't expanded would be immediately barred from doing so.

And it would allow states to relax some key Obamacare protections of those with pre-existing conditions, which are among the health reform law's most popular provisions. States could apply for waivers to allow insurers to offer skimpier policies that don't cover the 10 essential health benefits mandated by Obamacare. Also, insurers would be able to charge higher premiums to those with medical issues if they let their coverage lapse. States requesting waivers would have to set up programs -- such as high-risk pools -- to protect insurers from high-cost patients.

An eleventh-hour amendment that helped seal the missing GOP votes would add $8 billion over five years to fund high-risk pools and go toward patients with pre-existing conditions in states that seek waivers under the Republican legislation. The legislation already included $130 billion in the fund.

However, the GOP bill doesn't touch one beloved piece of Obamacare -- letting children stay on their parents' insurance plans until the age of 26.</s>House Republicans voted Thursday to pass the American Health Care Act – their answer to ObamaCare.

The bill has gone through some changes since an earlier version was pulled from the floor in March in the face of flagging support.

Here’s what’s the bill does:

-Ends tax penalties, under the original Affordable Care Act, for individuals who don’t buy insurance coverage and larger employers who don’t offer coverage. Instead, insurers would apply a 30 percent surcharge to customers who've let coverage lapse for more than 63 days in the past year.

-Ends tax increases on higher-earning people and a range of industry groups including insurers, drug makers and medical device manufacturers.

-Cuts the Medicaid program for low-income people and lets states impose work requirements on Medicaid recipients. Forbids states that haven't already expanded Medicaid to do so. Changes Medicaid from an open-ended program that covers beneficiaries' costs to one that gives states fixed amounts of money annually.

-Overhauls insurance subsidy system from one based largely on incomes and premium costs to a system of tax credits. The credits would rise with customers’ ages and, like the subsidies, could be used toward premium costs.

-Lets states get federal waivers allowing insurers to charge older customers higher premiums than younger ones by as much as they'd like. Obama's law limits the difference to a 3-1 ratio. States also can get waivers exempting insurers from providing consumers with required coverage of specified health services, and from Obama's prohibition against insurers charging higher premiums to people with pre-existing health problems, but only if the person has had a gap in insurance coverage.

-States could only get the latter waivers if they have mechanisms like high-risk pools that are supposed to help cover people with serious, expensive-to-treat diseases. A newly added provision would give another $8 billion over five years to help states finance their high-risk pools. Despite criticism that the waivers strip protections, House Speaker Paul Ryan’s office maintains that since states that take the waivers would have to set up the high-risk pools, “insurance companies cannot deny you coverage based on pre-existing conditions.”

-Blocks federal payments to Planned Parenthood for a year.

-Retains requirement that family policies cover grown children to age 26.

The Associated Press contributed to this report.</s>WASHINGTON (CN) – Two votes on Thursday delivered House Republicans a win they had been plotting for seven years: passing a replacement for the Affordable Care Act.

The 217-213 vote came just one day after the release of a key amendment offered by Rep. Fred Upton that provides an additional $8 billion over five years to help people unable to afford health insurance cover their premiums.

Upton had been a prominent holdout on the bill but his addition was a key pick up to free up moderate Republicans to vote in favor.

The bill needed 216 yes votes to pass. All 193 Democrats in the House voted no. They were joined by 20 Republicans who dissented.

The bill now heads to the Senate, where it figures to face an even tougher fight with a much more narrow Republican advantage.

But that didn’t dampen the celebratory mood of Republican lawmakers as they gathered in the White House Rose Garden Friday afternoon with President Donald Trump.

Of the bill’s immediate future, the president said, “The journey continues,” assuring his fellow Republicans “We will get it done.”

So jubilant was Trump that he said, “I even want to thank the media.”

The Congressional Budget Office has not yet rated the latest version, though its analysis of the earlier version found that 14 million people would lose their health insurance under the law in 2018.

The report also found that premiums would increase by 15 to 20 percent in the near-term.

Republicans have for years complained Democrats rushed the Affordable Care Act through the legislative process in 2010 but on Thursday they insisted the fast-track scoring of their bill was enough, even with the amendments tacked on at virtually the last minute.

“I think it will make it better because we’re actually putting more money into the plan and we’re giving states more flexibility,” Rep. Raul Labrador, R-Idaho, told reporters Thursday, referring to the amendments.

Thursday morning, with just hours to go before the vote, Rep. Peter King, a New York Republican who tentatively supported the bill, said he had not read Upton’s amendment but was planning to go back to his office to do so before the vote.

“You have to strike while you can,” King told reporters on Thursday morning, supporting leadership’s decision to hold the vote.

Democrats accused Republicans of trying to force the bill through before a CBO report came out so they could shield the legislation from a bad rating.

“They’re terrified of the facts of what that CBO report would say,” House Minority Leader Nancy Pelosi told reporters at a press conference Thursday.

Even some Republicans in the Senate raised concerns about how the bill moved through the House, a break in the silence that had settled over GOP members of the Senate.

“A bill — finalized yesterday, has not be scored, amendments not allowed and 3 hours final debate — should be viewed with caution,” Sen. Lindsey Graham tweeted on Thursday before the vote.

It was unclear even in the hours immediately leading up to the vote whether Republicans would be able to keep enough of their own to pass the bill. House leaders had to pull a previous iteration of the bill after a poor Congressional Budget Office report made it politically unfeasible for both the conservative wing of the party and its more moderate members.

The second amendment that helped revive the bill, sponsored by Rep. Tom MacArthur, allows states to opt out of certain regulations contained in the Affordable Care Act if they show doing so would either reduce premiums, increase enrollment, bring stability to the insurance market or to people with preexisting conditions or increase choice for insurers.

If they receive a waiver, states could set their own requirements for what insurers must cover, vary the amount by which insurers can charge older people more than younger people or allow insurers to charge people with preexisting conditions more if they don’t keep continuous coverage so long as the states also offer safety nets for people with higher premiums.

This last provision was especially controversial among the bill’s skeptics. Critics argued that even though the amendment explicitly proclaimed it was not meant to impact the coverage of people with preexisting conditions, it would in effect create two categories of premiums, one were people are charged based on how healthy they are and another that pools healthy and sick people together.

Critics of the bill, which includes a number of health providers and advocate groups, say healthy people would likely flee to the one that charges people based on health, leaving sick people forced to pay higher premiums.

Republicans insist, however, that allowing states to opt out of the Affordable Care Act will give places with fewer health insurance options more flexibility. They also argue it will bring down costs, something the original CBO score agreed would eventually happen, though not until 2020.

“More people will be helped by this plan than under Obamacare,” Labrador said Thursday. “Because more people will have their premiums lowered, more people will have lower out-of-pocket costs, more people will have access to these high-risk pools and the states that take advantage of it, they will actually do better than the states that don’t.”

The bill would repeal Affordable Care Act’s individual mandate, instead replacing it with an option for insurers to hit people who do not keep continuous coverage with a 30 percent surcharge on their premiums. It also rolls back the provision of the Affordable Care Act that allowed 31 states to expand Medicaid .

The bill also repeals many of Affordable Care Act ‘s taxes and subsidies and protections that only allow insurers to charge older people three times as more than younger people. Just before passing the full bill the House voted to remove a portion that would have exempted members of Congress and their staffs from the state waiver provisions.

“Finally, after years of waiting we have the chance to do something good today,” House Majority Leader Kevin McCarthy said on the floor shortly before the vote to pass the bill.

Members hotly debated the bill on the House floor before the vote, with Speaker of the House Paul Ryan and Pelosi closing out the debate with impassioned speeches that ended in standing ovations from their respective caucuses. Republicans cheered as the vote counter in the House chamber ticked to 216, signifying the bill’s passage.

Democrats then responded by singing the famous chorus from Steam’s 1969 hit “Na Na Hey Hey Kiss Him Goodbye,” a nod to the disastrous electoral consequences Democrats have predicted would befall Republicans if they passed the bill.

“Na na na na, hey hey hey, goodbye,” Democrats sang while waiving to their colleagues across the aisle.</s>By Ed O’keefe, Paige Winfield Cunningham and Amy Goldstein, The Washington Post

WASHINGTON – House Republicans narrowly passed a controversial bill to revise Affordable Care Act, fulfilling a major Trump campaign promise but sending the measure on to an uncertain fate in the closely divided Senate.

Passage in the House by a vote of 217 to 213 capped weeks of fits and starts for the GOP and represented an enormous victory for President Donald Trump, who repeatedly pledged on the campaign trail last year to repeal and replace Obamacare but has struggled to secure legislative wins early in his president. The vote was also a big win for House Speaker Paul D. Ryan, R-Wis., who has been working on the legislation since January but has failed to unite his ideologically divided caucus.

“Today, this House has the opportunity to do more than just fulfill a promise,” Ryan said to the House chamber moments before the vote. “We have the opportunity to raise our gaze and set a bold course for our country.”

He continued: “This bill delivers on the promises that we have made to the American people. You know, a lot of us have been waiting seven years to cast this vote. Many of us are here because we pledged to cast this very vote – to repeal and replace Obamacare, to rescue people from this collapsing law. Are we going to meet this test? Are we going to be men and women of our word?”

Several White House aides began Thursday morning by texting each other and reporters with two words: “game day.”

“We’ll have the votes. This will pass,” House Majority Leader Kevin McCarthy, R-Calif., vowed on Thursday morning.

Democrats, meanwhile, predicted that the measure would be devastating for Americans’ health-care coverage but also, on a political level, for Republicans who voted for it.

House Minority Leader Nancy Pelosi, D-Calif., noted that many Americans can’t name their member of Congress, but that Thursday’s vote is set to capture the nation’s ire.

“You will glow in the dark on this one,” Pelosi warned. “So don’t walk the plank, especially unnecessarily.”

The vote caps a haphazard debate that included few public hearings and the hasty revision of key sections of the bill during closed-door meetings at both ends of Pennsylvania Avenue designed to secure votes from skeptical conservatives and moderates initially unwilling to support the legislation.

Despite more than six years of campaign pledges to undo the ACA and the recent changes to the legislation, several Republican lawmakers admitted Thursday that they have not read the bill or ignored questions about their understanding of the bill that were shouted by reporters. Republicans have accused Democrats in the past of ramming their health-care bill through without giving members a chance to absorb it – but on Thursday they insisted that they are not doing the same thing.

They argued that their health-care bill is only several hundred pages long, compared with the size of the Affordable Care Act, which ran several thousand pages.

Democrats “put a 2,000 page bill on the table they knew no one had time to read, and we’re not doing that,” said Rep. H. Morgan Griffith, R-Va.

“This is a rough and tumble exercise that the Founding Fathers anticipated,” he added.

House Freedom Caucus Chairman Mark Meadows, R-N.C., said he was willing to abandon his previous demands that leaders allow hearings and discussion of the legislation because members had opportunities to weigh in on amendments over the past several days. The decision marks a significant shift for hard-line Freedom Caucus members who have insisted that leaders give them ample time to read legislation and weigh in before a bill comes up for a vote.

“We’ve had members working with members to come up with real amendments that are getting adopted today,” Meadows said. “I can tell you that I have read the bill no less than six times. If they haven’t read the bill it is because they haven’t spent the time to do that.”

Republicans also disregarded the absence of a final cost estimate from the nonpartisan Congressional Budget Office – Congress’s official scorekeeper – on how much the bill would cost and how many people would receive health-care coverage. Several said that last-minute changes to the legislation won’t significantly change the final estimates.

“We’re still comfortable we’re saving billions and billions of dollars,” said Rep. Chris Collins, R-N.Y.

Though Republicans have for years spoken of repealing the ACA as a prime goal, the legislation would stop short of outright eliminating the 2010 health-care law enacted by a Democratic Congress and the Obama administration. Nevertheless, it would make a significant dent in large portions of current law.

In broad strokes, the bill represents an attempt to shift to a more conservative vision for the nation’s health-care policies. It would move from the federal government to states power to set important health insurance rules. It would end the ACA’s subsidies for most people who buy health plans through marketplaces created under the law, creating, instead, new tax credits with clear winners and losers. And it would rescind several taxes that have helped pay for the law, including ones imposed on Americans with high incomes, health insurers, medical devices and tanning salons.

The bill faces a steeper climb in the Senate, where widespread disagreement remains among Republicans about how to proceed on health care. First, the Senate’s parliamentarian – or rules-keeper – cannot review the legislation and determine the rules of debate until the CBO submits its official estimate, which could take several more weeks to complete, according to congressional aides. That would mean that official Senate debate on the bill could not begin until June.

Even then, the issue of health care reform is expected to be treated much more skeptically by Republican senators.

“A bill – finalized yesterday, has not been scored, amendments not allowed, and 3 hours final debate – should be viewed with caution,” Sen. Lindsey O. Graham, R-S.C., tweeted on Thursday ahead of the House vote.

Among many other concerns, GOP senators from states that have expanded Medicaid under the ACA have voiced concerns about rollbacks to that program included in the House bill. A trio of conservative senators – Ted Cruz, R-Texas, Mike Lee, R-Utah and Rand Paul, R-Ky. – who often buck GOP leaders are another wild card. With just a 52-48 advantage over Democrats, Senate Republicans have a smaller margin for error than their House counterparts.

The House measure may run into other procedural roadblocks in the Senate. The original proposal initially left many of the ACA’s insurance regulations alone – with the goal of ensuring it would pass muster with the Senate parliamentarian – but not all of them. The House’s version of the bill would undercut the ACA’s insurance regulations even more. That might make it difficult for Republican senators to pass the measure under a procedural maneuver known as “reconciliation,” which is usually reserved for budget legislation.

The legislation does not eliminate the ACA’s requirement that most Americans carry health insurance, but it would undercut that requirement by erasing the penalty for not having coverage. Instead, the bill would create a deterrent: enabling insurers to charge 30 percent higher premiums for one year to customers who have had a gap in coverage of at least about two months.

In the week leading up to the vote, a tug of war has played out among different wings of the House GOP over how much power states should have over insurance regulations. In the end, the bill incorporates two features advocated by the hard-right House Freedom Caucus. One would allow states to eliminate parts of the ACA that require insurers to include specific “essential health benefits” in health plans sold to individuals and small businesses, and set their own coverage requirements or none at all. The other would let states get federal permission to let insurers return to their old practice of charging more to customers with preexisting medical problems – a practice that the ACA outlaws.

An amendment last week freeing states to drop the same-price requirement for healthy and sick customers produced a backlash among some in the GOP conference. In the end, the bill includes $8 billion intended to be spread over five years to states that back out of this part of the ACA.

Medicaid would also be transformed in two ways. For the 31 states that, under the ACA, have expanded the safety-net program to include people with slightly higher incomes, the government would immediately stop paying for any one new to enroll under the expansion and would eventually stop the extra money the ACA has provided for that purpose. And starting in a few years, Medicaid would end its half-century tradition as an entitlement program in which the government pays a certain share for each person who enrolls, switching to a “cap” with a fixed amount per person – a change that would lessen federal funding.

Much of the recent contention among Republicans revolved around how to protect patients with expensive, preexisting conditions, prompting several amendments to the bill. Energy and Commerce Chairman Greg Walden presented those changes as improvements to the bill, in a slide presentation Thursday morning to his colleagues.

According to the slides, insurers could charge such patients more only if a number of conditions were met. States would have to get a waiver from the federal government and the individual would have to be uninsured and buying their coverage on the individual market.

No matter when and how Senate debate begins, House Republicans exhibited a palpable sense of relief Thursday that the issue is off their plates – at least for now.

Meadows, who struggled for weeks to rally his caucus around the measure, said the Senate will make changes he might not necessarily back.

Collins added that “only time will tell” whether the bill will have a chance in the House once the Senate changes it.

The Post’s Sean Sullivan, David Weigel, Kelsey Snell, Robert Costa and Paul Kane contributed to this report.</s>House Republican leaders plan to hold a vote on their health care bill Thursday, sending the strongest signal yet that enough support has been corralled to pass it.

Asked whether they had the votes needed to pass the bill, House Majority Leader Kevin McCarthy of California said Wednesday night, "Yes, we do."

Republicans have been working to piece together a GOP-only coalition of 216 votes ever since their attempt to repeal and replace much of the Affordable Care Act failed nearly two months ago. The House Rules Committee approved three major amendments Wednesday night, moving them along in time for a vote Thursday.

Rep. Tom MacArthur, R-New Jersey, the author of one of the amendments, told NBC News: "It's not a perfect bill — nobody says it is — but directionaly it's going in the right place."

The latest iteration of the American Heath Care Act aims to protect those with pre-existing conditions by adding $8 billion for five years to help people with long-term health issues afford care. Health care experts, however, say the amount is too little to address the needs, and several patient advocacy groups have come out against the bill.

Some members thought the additional funds were needed because of a previous change that would allow states to opt out of insurance mandates required by Obamacare that protect patients and consumers but that some conservatives blame for rising health care costs.

In the new version of the bill, states would be able to opt out of the requirement that insurers cover benefits such as maternity care, mental health care and hospitalization

And states that obtain waivers could charge those with pre-existing conditions much more. States would have to be able to show a mechanism for people to get coverage, such as high-risk pools. The Republican bill would provide $125 billion to help pay for the pools' high costs.

The White House and Republican leaders have spent the week putting on a full court press, holding numerous meetings and phone calls with members who are undecided or said they were against the bill. President Donald Trump has been personally lobbying lawmakers.

Vice President Mike Pence was on Capitol Hill every day this week, speaking to members individually to persuade them to vote for the bill.

Those efforts must have proven fruitful, because leaders had said they wouldn't hold a vote until they had enough votes to pass the measure.

House Democratic leader Nancy Pelosi of California said House Republicans would now be identified with the provisions in the bill.

"From the beginning, Trumpcare has meant higher health costs, more than 24 million hard-working Americans losing health coverage, gutting key protections, a crushing age tax, and stealing from Medicare," Pelosi said in a statement. "But tomorrow, House Republicans are going to tattoo this moral monstrosity to their foreheads, and the American people will hold them accountable."

Momentum for the bill increased after two members, including the influential Rep. Fred Upton, R-Michigan, former chairman of the Energy and Commerce Committee, said he'd support the bill. He's the one who helped usher in the additional money for those with pre-existing conditions.

As of Wednesday afternoon, 19 lawmakers said they were still opposed to the bill despite the changes, and more than two dozen said they were undecided. But the number seemed to have dwindled.

Two of those members — Reps. Dave Young, R-Iowa, and Jeff Denham, R-California — have said they were opposed, but they came out as co-sponsors of the Upton amendment, sending a message of support.

Health policy experts, however, said the additional $8 billion would not offset the cost of people with pre-existing conditions.

"This is a drop in the bucket," Matthew Fielder, a fellow at the Brookings Institution, told NBC News.

The AARP and several other patient advocacy groups have come out in opposition to the bill, claiming it would harm patients.

The complaints by Republicans came mostly from moderate Republicans who feared too steep cuts to Medicaid, high costs for those with pre-existing conditions, and too few resources for mental health needs and opioid addiction treatment.

Moderates were frustrated because many of the changes made to the bill were to accommodate conservatives' concerns. Previous additions to the bill would have phased out Medicaid much more quickly and put in work requirements for most able-bodied people who aren't the primary caregivers for children under the age of 6.

Republican leaders and the White House tried to address some concerns by promising to address members' health care priorities.

For instance, Republicans leaders promised Rep. Paul Gosar, R-Arizona, a vote on his bill that would reinstate the enforcement of anti-trust laws on insurance companies.

Members who aren't enthusiastic about the bill also had hopes that the Senate would make it more palatable.

Rep. Peter King, R-New York, said he's voting on it to "move the bill forward."

If the House passes it, the Senate would then try to pass the measure, but it would likely look much different coming out of the more moderate upper chamber.

Even with the changes in the past week, the non-partisan Congressional Budget Office will not analyze the bill for how much it will cost the federal government or its impact on consumers, Republican lawmakers said — raising sharp objections from Democrats.

"This process, to put it bluntly, is a godd--n mess," Rep. Jim McGovern, D-Massachusetts, told NBC News.

The bill would also repeal all of Obamacare's taxes, including a tax on couples making more than $259,000 per year. It would replace subsidies based on income with tax credits based on age to help people purchase insurance in the individual marketplace.

They are hoping to pass the bill before members head home for 12 days and can tell their constituents that they delivered on a multi-year campaign promise to repeal Obamacare.</s>As soon as the House approved the GOP health care bill on Thursday, Democrats were working on using it against Republicans in next year's midterm elections.

"They have this vote tattooed on them. This is a scar they carry," House Minority Leader Nancy Pelosi declared just after the American Health Care Act passed the House.

Just to rub it in, many Democrats on the House floor began singing "Na Na Hey Hey Kiss Him Goodbye" to their colleagues across the aisle after the vote, a moment of schadenfreude hoping for the same fate many of their own suffered after the Affordable Care Act passed in 2010.

Democrats need to flip 24 seats to win back the House in 2018, and the congressional vote to repeal and replace Obamacare may well have made that a much easier task. Some of the most vulnerable House Republicans voted in favor of the GOP health care plan on Thursday. No Democrats voted for it, while 20 Republicans opposed it, and it only eked by with 217 yay votes — one more than it needed to pass.

Even members who bit the bullet and voted yes, on what they admitted was an imperfect bill, sounded anything but certain about the vote they had just cast.

Florida Rep. Carlos Curbelo — who represents a Miami district Hillary Clinton won in 2016 by 16 points — made a "game-time decision" on the vote, his spokeswoman told the Miami Herald, and now will be looking to the Senate to smooth out some issues with the bill.

"Today's vote is just a step in the legislative process for this bill — not the end of it," Curbelo said in a taped statement. "We have worked hard to improve the legislation, but we have a long way to go."

It has yet to be scored by the nonpartisan Congressional Budget Office to determine how much the bill will cost or how many people could lose coverage. The CBO report in March on an earlier iteration of the bill predicted that 24 million fewer people would be covered.

Atop Democratic target lists for 2018 are the 23 Republicans who sit in districts that were won by Hillary Clinton last November. Of those members, 14 ended up voting for the bill, with just nine opposing it. One of those no votes, Florida Rep. Ileana Ros-Lehtinen, announced earlier this week she wasn't seeking re-election, so that's one open race Democrats are feeling hopeful about.

Many of the Republicans who ended up voting against the bill cited concerns that the legislation didn't do enough to protect people with pre-existing conditions — echoing a major attack line Democrats are already using, and will surely stick with over the next 18 months.

Moderate New Jersey Republican Tom MacArthur worked with members of the conservative Freedom Caucus to come up with an amendment to the GOP's American Health Care Act that allows states to seek waivers from Obamacare requirements, including on coverage for people with pre-existing conditions.

Further changes put more money towards so-called "high-risk pools" to help defray costs for people with pre-existing conditions. But NPR's Alison Kodjak reported that "an analysis released Thursday by consulting firm Avalere Health concludes that that amount would be inadequate for providing full health coverage for the number of people who now buy insurance in the individual market and have medical problems."

"At this time, I cannot support the AHCA with the MacArthur amendment because I'm concerned that a small percentage of those with preexisting conditions may still not be protected," Colorado Rep. Mike Coffman, who sits in a district Clinton won, said in his statement explaining his decision.

For Democrats, it's a pronounced turn of events since Obamacare passed in 2010. With Republicans riding high on the public opposition to the law, Democrats' majority in the House was decimated that year, with 63 seats and control of the House lost.

But sentiment has changed on Obamacare, with Gallup finding this month that 55 percent now approve of the ACA.

The AHCA faces a much tougher road in the Senate, and if it dies there some of those vulnerable GOP members may have taken what ends up being a futile vote.

But there's another side to consider, too. For Republicans who have made the refrain "repeal and replace Obamacare" their mantra for seven years now, not acting on their signature campaign promise could risk depleting enthusiasm among their core voters, who they also need to turn out in November 2018 to combat a Democratic base energized against Trump.

And after the first attempt at repeal failed in an embarrassing fashion, House Republicans and President Trump badly needed a win. That's why they took a victory lap in the White House Rose Garden on Thursday afternoon, even though the bill is far off from becoming law.

"The American people expected us to deliver on the promises we've made and that's what House Republicans have just done," National Republican Congressional Committee communications director Matt Gorman wrote in a memo after the vote.

Republicans have pointed out that more insurance companies are pulling out of state-run exchanges, and the GOP bill will cut about $765 billion in taxes over the next decade, NPR's Scott Horsley reported, though mostly for wealthy Americans.

Some Democratic operatives were already gloating on social media that the Rose Garden event provided great footage for attack ads against House Republicans next year.

Ultimately, for the most vulnerable House Republicans, this may be a vote they won't be able to escape over the next year and a half — even if it never becomes law.</s>On May 4, 2017, Republicans in Congress moved a huge step closer to their wish to repeal the Affordable Care Act, commonly referred to as “Obamacare.” The body voted 217 to 213 to adopt the American Health Care Act of 2017 (AHCA).

As the five-minute voting period ended, members could be heard singing, “Na na na na, na na na na, hey hey-ey, goodbye.”

Watch the debate and the vote here, via C-Span.

Next up: The Senate will debate and vote on the latest version of the AHCA.</s>The House is debating and expected to vote Thursday afternoon on the latest Republican measure to repeal and replace the Affordable Care Act.

The bill includes last-minute amendments designed to draw votes from the most conservative House Republicans in the House Freedom Caucus as well as from their more moderate counterparts.

GOP leaders are hoping the third time is the charm for their measure. The original bill was pulled from the floor in March when it became apparent it would not pass. And last week, they considered but then decided not to risk another vote.

Republican members had their arms twisted by President Trump in phone calls, and attended a last minute pep rally Thursday morning, in which GOP House leaders reportedly told them it was "time to live or die by this day."

The measure, known as the American Health Care Act, is not expected to receive any support from Democrats, and so Republicans will have to come up with the necessary 216 votes to pass the bill and send it on to the Senate on their own.

House Minority Leader Nancy Pelosi calls the measure "a monstrosity," and said "Republicans have made Trumpcare even more dangerous and destructive than the last time they brought it to the floor."

House members will be voting on a bill without any knowledge of how many Americans will be affected, or the measure's price tag. That's because the Congressional Budget Office, the official scorekeeper, hasn't had a chance to analyze the amended bill. But the CBO estimated an earlier version of the measure would mean 24 million people could lose their insurance.

But we do know the bill would cut taxes imposed by the Affordable Care Act, and slash funding for Medicaid, which was expanded under the ACA, by more than $800 billion. It would also allow states to seek waivers for many of the patient protections in Obamacare, including for those with pre-existing conditions.

The measure does provide $8 billion for states to set up high-risk pools to cover people with pre-existing conditions who were unable to find affordable coverage on the open market. That last-minute addition was key to winning support from some House Republicans were concerned about coverage for pre-existing conditions. But critics say it's woefully short of the amount of money actually necessary to guarantee affordable coverage.

An array of medical groups, led by the American Medical Association, oppose the measure. In a statement, AMA President Andrew Gurman said "None of the legislative tweaks under consideration changes the serious harm to patients and the health care delivery system if AHCA passes. Proposed changes to the bill tinker at the edges without remedying the fundamental failing of the bill --that millions of Americans will lose their health insurance as a direct result of this proposal."

The retirees' group AARP also opposes the GOP bill.

But passing the measure would be a step toward keeping one of President Trump's central campaign vows, and fulfilling Republicans' long stated goal of overturning Obamacare, as the Affordable Care Act is also known.

Whether the Senate will go along is another story. Few Senate Republicans have expressed any interest in the House plan, and it's expected to be significantly altered if it reaches that chamber. And polls have shown the GOP measure to be extremely unpopular with voters, potentially placing at risk the political careers of lawmakers who back it.</s>The House of Representatives is slated to vote on a new health care bill Thursday that will repeal and replace the Affordable Care Act (ACA), just six weeks after an earlier GOP bill was abandoned amid concerns it would not pass in the House.

The vote is expected to take place early Thursday afternoon, according to the Associated Press. Republicans can afford to lose 22 votes for the bill to pass.

The bill has been controversial, largely because of debate on whether people with pre-existing conditions would be covered, as they are under the ACA. In response, lawmakers have amended it to cover those with pre-existing conditions . But as the AP notes, experts worry the bill would allow insurers to set premiums based on people's health — meaning those who are sick would most likely have to pay more.

Still, some Republicans are optimistic it will pass, as House Majority Leader Kevin McCarthy (R-Calif.) told reporters on Wednesday.</s>Republicans approved their plan to replace the Affordable Care Act on Thursday.

Here's a rundown of key provisions in the American Health Care Act and what would happen if the Senate approves them and the bill becomes law.

The bill would no longer require people to buy insurance through the marketplaces created by the Affordable Care Act, also known as Obamacare, if they want to use federal tax credits to buy coverage. It also would eliminate the tax penalty for failing to have health insurance coverage, effectively eliminating that requirement altogether.

In place of that mandate, the bill encourages people to maintain coverage by prohibiting insurance companies from cutting them off or charging more for pre-existing conditions for as long as their insurance doesn't lapse. If coverage is interrupted for more than 63 days, however, insurers can charge people a 30 percent penalty over their premium for one year.

The House Republican plan would eliminate the income-based tax credits and subsidies available under the Affordable Care Act, replacing them with age-based tax credits ranging from $2,000 a year for people in their 20s to $4,000 a year for those older than 60.

That means some people will see their costs go up while others would pay less, depending on your age and where you live. This Kaiser Family Foundation interactive map shows how the change would play out across the country.

The map shows that a 27-year-old who makes $30,000 a year would see their costs rise about $2,000 in Nebraska, but fall by about the same amount in Washington. A 60-year-old however, would see costs rise almost everywhere, with increases of almost $20,000 a year in Nebraska.

Both Kaiser and the Congressional Budget Office found that on average, older people with lower incomes would be worse off under the Republican plan than under the Affordable Care Act.

The bill eliminates nearly all the taxes that were included in the Affordable Care act to pay for the subsidies that help people buy insurance. Those cuts, which add up to about $592 billion, include a tax on incomes over $200,000 (or $250,000 for a married couple); a tax on health insurers and a limit on how much insurance companies can deduct for executive pay; and a tax on medical-device manufacturers.

The AHCA would make dramatic changes to the Medicaid program, which is the federal –state health program for the poor and disabled.

The Affordable Care Act allows states to expand eligibility for Medicaid to single, non-disabled adults with incomes slightly above the poverty line, with the federal government picking up most of the cost. That meant single adults who earn up to $15,800 a year could qualify in the 31 states, plus the District of Columbia, that expanded Medicaid. About 10 million people enrolled under that expansion.

The Republican plan would gradually roll back that expansion starting in 2019 by cutting the federal reimbursement to states for anyone who leaves the Medicaid rolls. People often cycle in and out of the program as their income fluctuates, so the result would likely be ever-dwindling numbers covered.

The House bill also converts Medicaid from an entitlement program where the government pays all the health-related costs for those who qualify, into a grant program. The federal government would give states either a set amount of money for each Medicaid enrollee, or states can choose to receive a fixed-dollar block grant.

The Congressional Budget Office estimated in March that the bill would cut Medicaid spending by $880 billion.

The AHCA maintains protections for people with pre-existing conditions, with some important exceptions (see waivers, below). That means that someone with high medical expenses pays the same premium for the same policy as anyone else their age in their area.

This section of the bill essentially amounts to an optional, state-level full repeal of Obamacare. It would give states the ability to apply for a waiver that lets them opt out of most of the regulations and consumer protections that were included in the Affordable Care Act.

States could apply for waivers that allow insurance companies in their states to do three things: 1) Charge older people more than five times what they charge young people for the same policy; 2) Eliminate required coverage, called essential health benefits including maternity care, mental health and prescription drugs, required under the Affordable Care Act; and 3) Charge more or deny coverage to people who have pre-existing health conditions, such as cancer, diabetes or arthritis.

The waivers could also impact people with-employer based insurance, because they would allow insurers to offer policies that have annual and lifetime benefit limits, which are banned under the Affordable Care Act, and some companies may choose those policies for their workers to lower their premiums.

States that get waivers would likely see insurance companies offer many more policy options, some with fewer benefits and lower premiums.

Those states would be required under the law to create some other way to ensure that people with expensive illnesses are able to get health care, and the law provides up to $138 billion over 10 years for such programs, typically called high-risk pools.

However, an analysis released Thursday by the consulting form Avalere concludes that that amount would be inadequate to provide full health coverage for the number of people who now buy insurance in the individual market and have medical problems.

The House approved the bill Thursday without a full analysis by the Congressional Budget Office of its costs and how many people would be covered.

The CBO report from March concluded that over 10 years, 24 million fewer people would be covered under the bill who otherwise would have had insurance under current law.

That analysis also predicted that the House bill would cut the federal deficit by $337 billion over those same 10 years.

However, changes to the bill since then would allow states to accept block grants for Medicaid; add about $38 billion for high-risk pools and maternity and childbirth care; and offer states waivers from regulations created by the Affordable Care Act. It's unclear how much these changes would affect the original CBO score.
The Republican-controlled United States House of Representatives votes in favor of the repeal of the 2010 Patient Protection and Affordable Care Act and passage of the House's 2017 American Health Care Act, by a narrow, 217–213 vote. Twenty Republicans and all Democrats opposed the bill, which now heads to the United States Senate for its legislative action.