May 4 (UPI) -- Less than two months after their last attempt to pass the American Health Care Act failed in embarrassing fashion, House Republicans on Thursday narrowly approved a revised version of the proposal -- and, some note, without even knowing what its full impact will be.
After weeks of negotiations, House Republicans passed the bill aimed at repealing much of the Affordable Care Act and replacing it with a system they say will offer similar benefits, only at a lower cost.
The House voted 217-213 for the AHCA Thursday, barely enough to send it on to the Senate. Twenty Republicans and every Democrat voted against the bill.
The passage gives President Donald Trump and House Speaker Paul Ryan a marginal victory after their previous attempt to repeal and replace the ACA failed on March 24, when Republicans were forced to pull the bill because it didn't have the necessary votes. Trump said at the time he would move on to other issues and "let Obamacare explode."
Although the AHCA passed the House by just four votes -- and faces an uphill climb in the Senate -- Trump and GOP leadership pumped up the victory at a ceremony in the Rose Garden of the White House Thursday.
"What a great group of people," Trump said of the Republicans applauding around him at the ceremony. "And they're not even doing it for the party. They're doing it for this country because we suffered with Obamacare. ... People were suffering.
"We are going to get this passed through the Senate. I am so confident. ... This is a great plan. I actually think it will get even better. Make no mistake, this is a repeal and a replace of Obamacare."
"We've taken a historic first step to repeal and replace Obamacare and finally give the American people the kind of healthcare they deserve," Pence said.
"We have a failing health care -- I shouldn't say this to our great gentleman and my friend from Australia because you have better health care than we do," he said.
Sen. Bernie Sanders, I-Vt., an advocate for a government-run universal health care option, jumped on Trump's comment.
"The president has just said it. That's great. Let's take a look at the Australian health care system, and let's move," Sanders said in an interview on MSNBC. "Maybe he wants to take a look at the Canadian health care system or systems throughout Europe. Thank you, Mr. President. Let us move to a Medicare-for-all system that does what every other major country does."
The AHCA bill was passed on Thursday before the Congressional Budget Office, the non-partisan congressional scorekeeper, could produce a final estimate of its cost and impact. That means Republicans voted to approve their plan without knowing exactly how it would affect the federal budget -- or the millions of Americans who potentially stand to lose their medical insurance.
The CBO analysis of two failed versions of the AHCA in March -- the original bill and one with amendments -- said the GOP plan would cause 24 million people to lose their coverage by 2026.
In fact, the CBO analysis alone was reason enough for some Republicans to reject the AHCA last time.
"Forcing a vote without a CBO score shows that Republicans are terrified of the public learning the full consequences of their plan to push Americans with pre-existing conditions into the cold," House Minority Leader Nancy Pelosi said in a statement. "With each passing week, Republicans have only made their bill more costly and more cruel to American families."
Some critics took Ryan to task for doing exactly what he condemned eight years ago when Democrats were working on the ACA.
"Before Congress changes health care as the American people know it, we must know the likely consequences of the House Democrat legislation, including the number of people who would lose access to their current insurance, the number of jobs lost due to business taxes, the number of uninsured people who would obtain coverage, and the extent of the cannibalization of employer coverage due to Medicaid expansion" a letter to the CBO, signed by Ryan, stated.
"I don't think we should pass bills that we haven't read, that we don't know what they cost," he also said that year.
The bill now advances to the Senate, where it will face more challenges -- as the upper chamber gives far more power to individual members to hold up passage and force changes. Further, bills that barely escape the House rarely do well in the Senate, where the gap between Republican and Democratic members is much smaller (four seats).
"House Republicans are going to tattoo this moral monstrosity to their foreheads, and the American people will hold them accountable," Pelosi added.
House Democrats lambasted the new attempt to pass the proposal as disastrous for millions of Americans, who they say would lose basic ACA-granted protections under the new law -- including the rule that makes it illegal for insurance companies to deny coverage for pre-existing medical conditions.
Democratic representatives serenaded Republicans with a chorus of "na na na na, hey hey hey good-bye" -- a popular taunt aimed at losing teams during sporting events -- as the votes were tallied Thursday, a show of confidence that the bill will prove a political albatross in the upper chamber.
The bill will also face more tugs-of-war between GOP conservatives and moderates in the Senate. Several Republicans in the chamber have already echoed Democratic concerns that the AHCA doesn't do enough to protect individuals from high premiums and refusal of service if they lose their coverage.
The retooled Republican bill faced intense opposition within the GOP caucus from disparate groups. The initial version was rejected by the House Freedom Caucus -- a group of about 30 of the chamber's most conservative members -- because they felt the measure didn't go far enough.
They argued the AHCA left too much of the ACA's regulatory infrastructure and taxes in place. As Trump and Ryan worked to amend the bill to mollify conservatives, the other end of the Republican ideological spectrum, GOP moderates from the Northeast, then began to oppose.
Additionally, many in the GOP's more centrist wing come from areas where the ACA is popular -- and feared recoil from constituents who can lose coverage or face higher premiums under the new law, similarly called "Trumpcare."
In the end, a deal was struck between the rival factions. Conservatives successfully added an amendment that would allow individual states to opt out of ACA regulations on pre-existing conditions, as well as rules against charging women more than men. In exchange, the legislation requires those states to set up "high risk pools" to help offset the expense of insurance for the poorest and sickest individuals -- for which Republicans negotiated an additional $8 billion to help underwrite the cost.
Some Democrats scoffed at the GOP's plan to create high-risk pools, arguing that the money set aside will pale in comparison to the costs facing healthcare providers -- whose huge medical bills will be passed onto patients or absorbed into the overall system, causing rates to rise for everyone.
States that apply for the waiver would also let insurance companies sidestep certain ACA standards -- meaning companies would once again be allowed to nix coverage for prescriptions, child birth and birth control, and force patients to pay thousands of dollars in deductibles before the insurance starts to pay for anything.
The AHCA also repeals the so-called "individual mandate," a controversial part of the ACA that required all American citizens to buy health insurance or pay a fine.
Democrats have said the result of the AHCA will be millions of Americans forced to choose between buying plans they can't afford or ones that are not worth the investment.
Republicans, though, say those very problems are already causing trouble as a result of the ACA's onerous regulations and taxes. They pointed to several states where insurers have refused to offer plans and premiums have increased by more than 50 percent in recent years, stretching government expenditures and making plans scarcely available or too expensive for people to buy.
Thursday's vote occurred a day before the House takes a one-week recess. Leaders said they wanted the vote held before the break so lawmakers won't be swayed by angry constituents and well-funded industry groups blanketing airwaves with attack ads -- like the ones Democrats faced seven years ago as they debated Obama's signature healthcare law.
The Republican victory Thursday came despite a huge lobbying push by traditional Democratic groups and non-profits that created a wall of opposition. The Association of American Retired People, American Medical Association, the Hospital Association, the American Heart Association, the American Cancer Association and other disease-specific lobbying groups came out against the AHCA.
AMA President Dr. Andrew Gurman released a letter signed by 10 non-profit industry groups that said, "millions of Americans will lose their health insurance as a direct result of this proposal."