Republicans are claiming a triumph by pushing their legislative centerpiece scuttling much of President Barack Obama's health care law through the House. It was a perilous journey, and its Senate pathway will be at least as bumpy with little doubt the measure will change, assuming it survives.
Thursday's 217-213 House passage — with 20 GOP defections — was preceded by several near-death experiences for the legislation, even though repealing Obama's statute helped guide Donald Trump's presidential run and multitudes of GOP congressional campaigns.
And that was in a chamber Republicans control 238-193. Had just two additional Republicans voted "no," the measure would have lost because bills need majorities to pass. Now, Republicans must try maneuvering the measure through a Senate terrain that is different politically and procedurally from the House.
"We must manage expectations and remain focused on the art of the doable as we move forward," said Senate Finance Committee Chairman Orrin Hatch, R-Utah, among several cautionary statements issued by Senate Republicans after the House vote.
The House bill would end the Obama law's fines on people who don't purchase policies and erase its taxes on health industry businesses and higher-earning people. It would dilute Obama's consumer-friendly insurance coverage requirements, like letting states permit insurers to charge higher premiums for customers with pre-existing medical conditions.
The measure would replace Obama's federal subsidies for lower-income insurance buyers with tax credits geared to consumers' ages. And it would cut Medicaid, the health insurance program for the poor and disabled, including ending extra federal payments 31 states are accepting to expand Medicaid to cover more people.
On Friday, critics of the legislation were using the "IAmAPreexistingCondition" hashtag on Twitter to express worries that the bill would deny coverage to people with serious illnesses like cancer or post-traumatic stress disorder.
The House bill bars insurers from refusing policies to extremely ill people. But opponents argue it effectively does that by letting insurers impose higher prices on some people with pre-existing illnesses and who let their coverage lapse. The bill includes billions of dollars to help those people, but experts say it's unlikely to be enough.
The House bill was written by Republicans representing districts often drawn to incorporate strong majorities of GOP voters. Senators represent entire states, and many tend to reflect more pragmatic views than their House colleagues.
Several come from northeastern and Midwestern states with large numbers of low-income people receiving Medicaid. Many of the 31 states that accepted Obama's expansion of that program are led by GOP governors, and senators have no interest in cutting their states' funds and taking coverage away from voters.
Republican senators also represent states ravaged by deaths caused by opioid abuse. The House measure would let states escape Obama's requirement that insurers cover anti-drug services.
"I've already made clear that I don't support the House bill as currently constructed," said Sen. Rob Portman, R-Ohio. He cited its Medicaid cuts, including for treating people with drug problems, and said he'd make sure that "those who are impacted by this epidemic can continue to receive treatment."
In March, Portman joined three other GOP senators in opposing Medicaid cuts in an early version of the House legislation. In a letter to McConnell, they wrote that the measure "does not provide stability and certainty for individuals and families" who use the program.
Sen. Susan Collins, R-Maine, said the House bill poses "more questions than answers about its consequences." She said there should be "no barrier for coverage" for people with pre-existing medical conditions and that the House's tax credits "do not adequately take into account income levels" or regional differences in health costs.
Collins and Sen. Lisa Murkowski, R-Alaska, have opposed cutting federal money for Planned Parenthood. The House bill blocks federal payments for a year to the organization, which provides abortions but doesn't use federal funds for them by law.
Other senators are also seeking changes. No. 3 Senate GOP leader John Thune of South Dakota is working on a plan to skew the bill's tax subsidies more toward lower-income people.
States that did not expand Medicaid under Obama's law are looking for additional funding for their programs. Sen. Lindsey Graham, R-S.C., whose state did not enlarge Medicaid, said he would not back a health care bill "that rewards people for taking Medicaid expansion at the expense of those who did not."
Then there are senators like Ted Cruz of Texas and Rand Paul of Kentucky, former presidential candidates who seldom back away from fights and have already signaled they're looking for changes.
The Republican edge in the Senate is just 52-48. Using special rules, the Senate could pass its version of the bill with just 50 votes and rely on Vice President Mike Pence to break a tie. But that means they can lose just two GOP senators assuming Democrats uniformly oppose scrapping Obama's signature domestic achievement.
Those same bylaws bar provisions that aren't chiefly aimed at federal spending or revenue, meaning some House language dealing strictly with policy changes could fall out.
"The Senate will now finish work on our bill, but will take the time to get it right," said Sen. Lamar Alexander, R-Tenn., who chairs the Senate health committee.