In recrafting the bill, Mr. Ryan worked with an attentive White House, edging out the committee chairmen who had helped write the original measure and turning to conservatives. This moved the bill significantly to the right. It also empowered the conservatives, whom many Republican leaders had hoped to marginalize in the era of Mr. Trump.
The president’s economic populism and flexibility on policy seemed at first to be totally out of step with the far-right members who essentially ran Mr. Boehner out of town. The vote Thursday could serve as an augury for high-stakes spending and policy fights.
“This is definitely a win for the Freedom Caucus,” said Charlie Sykes the former conservative radio host and longtime friend of both Mr. Ryan and Reince Priebus, Mr. Trump’s chief of staff. Mr. Preibus made getting a health care bill passed in the House a career-defining moment for himself and he negotiated at length with the conservative lawmakers. “They moved the bill right and the moderates caved,” Mr. Sykes said. “That creates an interesting dynamic.”
To get his victory, Mr. Ryan cast aside many promises he had made when he became speaker, throwing together bills without hearings and a sinewy committee process, making back room side deals to buy off individual lawmakers, and voting for bills before the Congressional Budget Office could put a price tag on them.
This process alienated committee chairmen, whose work took a back seat to the efforts of an elusive chairman of the House Freedom Caucus, Representative Mark Meadows, Republican of North Carolina, and it chipped away at their authority. Mr. Meadows and his fellow conservatives, who have toiled for years as philosophical bomb throwers in the legislative process, got the attention of the White House, which worked hard to meet their needs and pressure moderates to come along.
Mr. Ryan spent much of April calling and visiting colleagues to get the measure passed. But in the end, there is little guarantee that the Senate will be able to live with the House bill. This is particularly true for senators from states where the Medicaid program expanded under Mr. Obama’s program. “Senate Republicans may look back on the appeasement of the Freedom Caucus as a poison pill,” Mr. Sykes said.
That sentiment was already being felt in the House.
“Members have been asked to vote for a bill that is particularly treacherous, that is going no where in the Senate,” said Representative Charlie Dent, the Pennsylvania Republican who has led the opposition among moderates. “This legislation will be gutted and we will have voted for a bill that will never become law. Will it cause headaches for people? Absolutely.”
The Times would like to hear from Americans who will be affected by the new plan repeal and replace major parts of the Affordable Care Act.
At the very least, the Senate will take far longer to get its legislative process going. And whatever it passes could end up being so far from the House version that no compromise between the two chambers can be attained. That would mirror the situation House Democrats faced in 2009 when they voted for a politically risky cap-and-trade bill that the Senate never took up. Many of them then lost their seats.
“I sincerely hope that the Senate won’t mimic the House and try to rush a bill through without hearings or debate or analysis,” Senator Chuck Schumer of New York, the Democratic leader, said on the Senate floor Thursday.
Mr. Schumer gave a preview of the Democratic blitz facing House Republicans — who will return to their districts for a week off to gauge the voter’s reaction — describing the measure as a “breathtakingly irresponsible piece of legislation that would endanger the health of tens of millions of Americans.”
Republicans have guessed that there would be political costs, especially with energized Democrats looking to beat back Mr. Trump’s agenda and make a run at retaking the House in 2018. But they have also bet that their own base has been long depressed by their inability to repeal the health care law, and believe the issue will generate needed energy.
“The upside for Republicans is that they can return to their districts and tell G.O.P. voters that they acted on a campaign promise,” said Nathan Gonzales, the editor of Inside Elections. “The downside is that the alternative may not go far enough for base Republicans, may go too far for moderate voters, and create a backlash that puts the House majority at risk in 2018.”
On Thursday, a united Republican front presented their floor vote as a rescue mission, unity exercise and moral imperative. “Everyone was talking about how this was the moment to save Americans,” from the current health care law said Representative Vicky Hartzler, Republican of Missouri. “We’re proud of this product.”
Source: New York Times