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Health care: What's next for GOP?
Pressure on for delivering final product after repeal of Obamacare
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In this Jan. 5 file photo, House Speaker Paul Ryan of Wis. holds his copy of insurance premium statistics during a news conference on Capitol Hill in Washington. Ryan urged the GOP-controlled House to pass a critical first step toward delivering relief from President Barack Obama's signature health care law as the chamber steamed ahead on legislation that is the first step toward repealing it and replacing it with something else. - photo by Associated Press

    WASHINGTON — Republicans have won a gateway victory in Congress in their seven-year trek toward scuttling President Barack Obama's health care law. Now with Donald Trump a week from taking the presidential oath, achieving that goal is possible, but the pressure is on for them to deliver a final product.

    With a near party-line 227-198 House vote, Congress gave final approval Friday to a budget that will ease passage of a still-unwritten bill replacing Obama's overhaul with a GOP edition. The budget — the Senate approved it Thursday — bars Democratic senators from blocking that future legislation with a filibuster.

    The budget's approval, with just nine Republicans in the House and one in the Senate voting no, signaled that the party is ready to charge into a defining battle that will be risky. While GOP candidates — including Trump — have run for years pledging to dismantle Obama's 2010 statute, internal divisions abound over how to do it and many Republicans are leery of stripping coverage from the 20 million Americans who gained it under that law.

    The budget "gives us the tools we need for a step-by-step approach to fix these problems and put Americans back in control of their health care," House Speaker Paul Ryan, R-Wis., said after the vote.

    Friday's roll call sets the stage for what likely will be weeks or months — at least — of GOP efforts to write legislation and push it through Congress. While that will be challenging, the alternative seems potentially devastating — gaining control of the White House and Congress but failing to deliver on a promise to repeal and replace Obama's law, which GOP voters despise.

    "I think the leaders will keep a very close watch on where the members stand before they roll the dice" on a vote on later legislation erasing that law, said Rep. Lou Barletta, R-Pa.

    Much of Friday's debate underscored the sharp-elbowed politics of the issue.

    "People in Michigan, Pennsylvania, Wisconsin, Ohio, screwed," said Rep. Hakeem Jeffries, D-N.Y., citing places where he said voters would suffer from the health law's repeal — which also were normally reliably Democratic states that Trump won on Election Day. Continuing the theme of highlighting Trump voters, Jeffries added, "People in Appalachia and rural America, screwed."

    Democrats praised the law for extending coverage to tens of millions of Americans and helping many millions more afford policies and buy prescriptions. Rep. John Yarmuth, D-Ky., said rather than "repeal and replace," Republicans should name their effort "repeal and repent" because of the harm they were about to cause to voters.

    No. 3 House GOP leader Steve Scalise of Louisiana aimed his rhetoric at Democrats defending one of Obama's proudest legislative achievements, a law that Republicans say missed its goals of cutting consumers' medical costs and increasing access to doctors.

    "This should not be about preserving somebody's legacy," Scalise said. "It should be about fulfilling those promises to the American people that were broken."

    Approval of the budget means Senate Democrats won't be allowed to filibuster the future repeal-and-replace bill — a pivotal advantage for Republicans. They control the Senate 52-48, but it takes 60 votes to end filibusters, which are endless procedural delays that can scuttle legislation.

    Congressional Republicans have made annulling Obama's law and replacing it a top goal for the past seven years. GOP rifts and an Obama veto prevented them from achieving anything other than holding scores of votes that served as political messaging.

    Trump also made targeting Obama's statute a primary target during his campaign. At his news conference Wednesday, Trump — who's supplied few details of what he wants — said his emerging plan will be "far less expensive and far better" than the statute.

    Despite their conceptual unity, plenty of Republicans have shown skittishness about the political repercussions of plunging into a battle that, with Trump in the White House, puts enacting new laws within reach.

    Many congressional Republicans expressed opposition to leaders' initial emphasis on first passing a repeal bill and then focusing on a replacement — a process that could produce a gap of months or longer. Trump has also pushed Congress to act fast.

    Many Republicans have insisted on learning how their party will re-craft the nation's $3 trillion-a-year health care system before voting to void existing programs.

    There are internal GOP chasms over Republican leaders' plans to use their bill to halt federal payments to Planned Parenthood and pare Medicaid coverage. There are also disagreements over how to pay for the GOP replacement, with many Republicans leery of Ryan's proposal to tax part of the value of some health insurance provided by employers.

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