This article originally appeared in TIME.
House Republicans voted on Thursday to repeal Obamacare, making good on a seven-year campaign promise that could reshape health care in the United States and dramatically reduce the number of Americans with health insurance.
If the Republican bill passes in the Senate, it will reorganize insurance markets and affect coverage for many millions of Americans.
“Seven years of Obamacare is enough,” House Speaker Paul Ryan wrote on Twitter Thursday morning.
The vote comes nearly six weeks after House Republicans had to pull an earlier version due to disagreements between moderates and conservatives in their caucus. The bill has since been amended twice, though the broad outlines remain the same.
The bill weakens protections for people with pre-existing medical conditions. It rolls back the expansion of Medicaid and cuts taxes on the wealthy. It also significantly reduces federal assistance to lower-income Americans paying for health insurance. It also significantly reduces federal assistance to lower-income Americans paying for health insurance, and it defunds Planned Parenthood.
In addition, it repeals the Obamacare “individual mandate,” the rule requiring people to buy insurance.
“This bill brings choice and competition back into the health care marketplace and puts health care decisions back in the hands of patients and doctors,” Rep. Diane Black said on the floor of the House. “It’s been a winding road to get to this point, but we’re here today to fulfill the promise we made to the American people.”
Called the American Health Care Act, the bill was passed on Thursday morning without a score from the nonpartisan Congressional Budget Office, which is highly unusual for major legislation. But a similar, earlier version of the Republican bill would have reduced the number of insured by 24 million people by 2026 and raised premiums by 15 to 20% before they began to drop, according to the CBO.
Democrats decried the bill, saying it was rushed through the House without enough review and would damage the health care system. “Republicans are maliciously again attempting to destroy healthcare and coverage for the American people,” said House Minority Leader Nancy Pelosi.
The vote on Thursday morning was a nailbiter.
Many Republicans — including those who voted for it — were privately unhappy with health care bill. For conservatives who wanted to repeal Obamacare fully, it does not go far enough; for moderates, it is too harsh on lower- and middle-income Americans. The bill is a “technocratic crap sandwich,” one Republican lawmaker said.
In addition, the bill comes without a score from the CBO, and some members felt the bill was rushed to the floor without members having time to understand the effects of the bill.
Rep. Peter King of New York said he had not read the latest amendment just hours before the vote, but that he would vote in favor anyway based on his discussions with Republican leadership. “You have to strike while you can,” King said.
For some, assurances from leadership were not enough. “I’m certainly not going to vote on a bill of this magnitude that hasn’t been fully scored by the Congressional Budget Office and whose price tag is unknown,” said Rep. Mike Coffman, Republican of Colorado.
But Republicans in the House, embarrassed by their failed effort to pass the bill at the end of March, were determined to push the health care on to the Senate. It will almost certainly face a significant overhaul in the Senate, and then be sent to a joint-chamber conference committee, where changes are reconciled.
Republican House members described the bill as a first-draft effort, necessary to begin the repeal of Obamacare. Waiting any longer, some Republicans said, could cause the bill to fail.
“If we couldn’t get this across the floor it would all stop here today,” said Rep. Tom Cole of Oklahoma. “Nobody should look at this as the be-all and end-all. It’s the first step, not the last step.”
“I don’t think time would be our friend. We want to get it over to the Senate so they can start their job,” said Rep. Chris Collins of New York.
But as a legislative blueprint, the House bill significantly weakens the protections established under Obamacare for Americans with preexisting conditions. It also will cut aid to lower-income Americans, making health care subsidies based on age, rather than income.
Those who stand to gain immediately include younger and healthier insurance buyers in the open marketplace, and the wealthiest taxpayers, who will see a significant tax cut.
The farthest-reaching effect of the American Health Care Act, however, may be provisions that roll back the expansion of Medicaid beginning in 2018. Obamacare expanded Medicaid for states who chose to opt-in to everyone making up to 138% of the poverty line, expanding coverage in those states by well over 10 million people.
Halting the Medicaid expansion in those states, combined with the bill’s restructuring of health insurance subsidies, will mean that people making minimum wage and slightly more will experience the sharpest drop in coverage.
“The AHCA would lead to catastrophic coverage losses among those right above the poverty line,” said Dr. Julie Donohue, director of the Medicaid Research Center at the University of Pittsburgh Health Policy Institute. “While individuals right above poverty-level could technically purchase coverage on the marketplace, such coverage will be out of reach for nearly all.”
President Trump has promised the bill would cover those with preexisting conditions, but the bill would allow states to let insurers charge people with preexisting conditions higher premiums.
Thursday’s House vote ensures that the Republican effort to repeal Obamacare does not end. But the Republican victory on Thursday may be setting lawmakers up for a major defeat in 2018.
The Republican health care bill is deeply unpopular, with just 17% of Americans approving of the bill, according to a poll from late March. The bill was opposed by AARP as well as the American Medical Association, health groups and hospitals. A majority of Americans want Congress to fix Obamacare rather than repeal it outright.
Democrats believe the bill’s passage on Thursday will help set up the party for a wave of congressional election victories next year. Even as they lambasted the Republican vote, Democrats were preparing to target the moderate Republicans in swing districts who voted for the bill.
“You vote for this bill, you’re walking the plank,” House Minority Leader Nancy Pelosi told Republicans on the house floor.
The bill “is going to provide a great civics lesson for America,” she said. “Most Americans don’t know who their Congressperson is. But they will now.”