Congress is poised to complete its initial step toward dismantling U.S. President Barack Obama's health care law, as Republicans divided over how to replace it face pressure from Donald Trump for quick action.
"We have a responsibility to step in and provide relief from this failing law," Speaker Paul Ryan told reporters Thursday. "And we have to do it all at the same time so that everybody sees what we're trying to do."
But at the same time, Ryan said there were no "hard deadlines" for a Republican replacement in tandem with the repeal effort, underscoring the difficulty for Congress despite the president-elect's call to both repeal the law and replace it with legislation to "get health care taken care of in this country."
That action will be almost impossible to fulfil in the complicated web of Congress, where Republican leaders must navigate complex Senate rules, united Democratic opposition and substantive policy disagreements among Republicans.
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By a near party-line 51-48 vote early Thursday, the Republican-run Senate approved a budget that eases the way for action on subsequent repeal legislation as early as next month. The Republican-controlled House planned to complete the budget on Friday, despite misgivings by some lawmakers.
2 parties aren't talking
Republicans are not close to agreement among themselves on what any replacement would look like.
The 2010 law extended health insurance to some 20 million Americans, prevented insurers from denying coverage for existing conditions and steered billions of dollars to states for the Medicaid health program for the poor. Republicans fought the effort tooth and nail, and voter opposition to the law helped carry the Republican Party to impressive victories in 2010, 2014 and last year.
Thursday's Senate procedural vote will set up special budget rules allowing the repeal vote to take place with a simple majority in the 100-member Senate, instead of the 60 votes required to move most legislation.
That means Republicans, who control 52 seats, can push through repeal legislation without Democratic co-operation. They're also discussing whether there are some elements of a replacement bill that could get through at the same time with a simple majority. But for many elements of a new health care law, Republicans are likely to need 60 votes and Democratic support, and at this point the two parties aren't even talking.
Kentucky Senator Rand Paul, unhappy that the measure endorsed huge budget deficits, was the sole Republican to vote against it.
'We're loading a gun here'
Increasing numbers of Republicans have expressed anxiety over obliterating the law without a replacement to show voters.
Senator Susan Collins, of Maine, said she wants at least to see "a detailed framework" of a Republican alternative health care plan before voting on repeal. She said Republicans would risk "people falling through the cracks or causing turmoil in insurance markets" if lawmakers voided Obama's statute without a replacement in hand.
Collins was among a handful of Republicans to occasionally break ranks to support some Democratic amendments aimed at supporting such things as rural hospitals and a mandate to cover patients with existing medical conditions. They were all shot down by majority Republicans anyway.
Ryan and other Republican leaders appeared confident that the measure would easily clear the House. In the House, both conservatives and moderates wanted to get more of a guarantee that the they would have a greater sense of what a Republican substitute would look like — or putting some elements of the replacement measure in the repeal bill.
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"We need to be voting for a replacement plan at the same time that we vote for repeal," said Representative Mark Meadows, of North Carolina, an influential conservative.
Some more moderate House Republicans were unhappy, too, including Representative Tom MacArthur, of New Jersey, a leader of centrists in the House Tuesday Group. He said he would oppose the budget because there was too little information about the replacement, including whether people receiving expanded Medicaid coverage or health care subsidies under the existing law would be protected.
"We're loading a gun here," MacArthur said. "I want to know where it's pointed before we start the process."