The Republican health care bill narrowly passed in the House Thursday, delivering a victory for President Donald Trump just six weeks after nearly leaving the measure for dead.
House approval sends the measure to an uncertain fate in the Senate, where some Republicans consider the bill too harsh. Polls have shown President Barack Obama's health care overhaul — which the GOP bill would largely repeal — has actually gained in popularity as the debate over a replacement health care program has accelerated.
The measure skirted through the House by a thin 217-213 vote, as all voting Democrats and 20 mostly moderate Republican holdouts voted no.
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Trump saluted the bill as "a great plan and I think it will get even better," saying more than once — "Make no mistake: this is a repeal and replace of Obamacare."
Beaten but unbowed, Democrats insisted Republicans will pay at election time for repealing major provisions of the law. They sang the pop song "Na Na Hey Hey Kiss Him Goodbye" to the GOP lawmakers as the end of the voting neared. The Republicans seemed unworried, many of them busing to the White House for a victory appearance with the president.
The vote on the American Health Care Act came after the House added several changes to insurance coverage requirements to the GOP's prized legislation. More than a dozen Republicans joined Democrats to allow the bill to pass by a wafer-thin margin.
Lawmakers heading to that celebrating were greeted with chants of "shame!" outside the Capitol.
Since it collapsed in March, the measure was revamped to attract most hard-line conservatives and some GOP centrists. In a final tweak, leaders added a modest pool of money to help people with pre-existing medical conditions afford coverage, a concern that caused a near-fatal rebellion among Republicans in recent days.
GOP candidates including Trump have made repealing Obama's statute an epitome of their campaign pledges since its enactment in 2010, claiming it's a failing system that's leaving people with rising health care costs and less access to care.
"It's time to live or die by this day," GOP leaders told the rank and file at an early morning, closed-door meeting to rally support, said Rep. Dennis Ross, R-Fla.
Democrats defended Obama's law, one of his crowning domestic achievements, for expanding coverage to 20 million Americans and forcing insurers to offer more generous benefits. They said the GOP measure would toss millions off coverage while delivering tax cuts to the wealthy.
"How can you do this to the American people, how can you do this to the people you represent?" asked Rep. Jim McGovern, D-Mass.
The bitter health care battle dominated the Capitol even as Congress prepared to give final approval to a bipartisan $1 trillion measure financing federal agencies through September.
The House passed that legislation Wednesday 309-118, and Senate passage seemed certain as early as Thursday. That would head off a weekend federal shutdown that both parties preferred to avoid —especially Republicans controlling the White House and Congress.
The health care vote was scheduled after the White House and congressional leaders barraged rank-and-file holdouts with pressure in recent days and claimed they had the votes to prevail.
Just Tuesday, The Associated Press had counted 21 Republicans saying they would oppose the bill — one short of the 22 defections that would kill it if all Democrats voted no. Many others were undecided.
"House Republicans are going to tattoo this moral monstrosity to their foreheads, and the American people will hold them accountable," House Minority Leader Nancy Pelosi, D-Calif., said Wednesday.
The bill would eliminate tax penalties Obama's law which has clamped down on people who don't buy coverage and it erases tax increases in the Affordable Care Act on higher-earning people and the health industry. It cuts the Medicaid program for low-income people and lets states impose work requirements on Medicaid recipients. It transforms Obama's subsidies for millions buying insurance — largely based on people's incomes and premium costs — into tax credits that rise with consumers' ages.
The measure would retain Obama's requirement that family policies cover grown children until age 26.
But 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 consumers to whatever they wish and ignore the 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 nonpartisan Congressional Budget Office estimated in March that the GOP bill would end coverage for 24 million people over a decade. That office also said the bill's subsidies would be less generous for many, especially lower-earning and older people not yet 65 and qualifying for Medicare.
A CBO estimate for the cost of latest version of their bill was not ready before the House conducted its vote.
Ryan pulled the plug on a March 24 vote as conservatives opposed the bill for not fully repealing Obama's law and GOP moderates considered its cuts too severe.
That was a jarring setback for Trump and Ryan. But leaders gradually rebuilt support, nailing down conservatives with provisions establishing the coverage waivers.
Earlier this week, moderates objected that constituents with pre-existing conditions could effectively be denied coverage by insurers charging them exorbitant premiums. At least a dozen of them said Wednesday they would oppose the legislation, including GOP Reps. Charlie Dent of Pennsylvania, a moderate leader, Leonard Lance of New Jersey and New York's Dan Donovan.
But GOP leaders seemed to win over a raft of wavering lawmakers after adding $8 billion over five years for state high-risk pools, aimed at helping seriously ill people pay expensive premiums. That was on top of $130 billion already in the bill for states to help customers, though critics said those amounts were insufficient.
To snuff out a glaring political liability, Republicans planned to approve a second bill. It would delete language in the health care measure entitling members of Congress and their staffs to Obama's coverage requirements, even if their home states annul them.
NBC editor Asher Klein and Associated Press writer Andrew Taylor contributed.