Shell-shocked Democrats on Capitol Hill are preparing to make a fight for Obamacare their top priority in the opening days of the Trump administration, with leading advocacy groups ready to wage “total war” to defend President Barack Obama’s universal health care program and his domestic policy legacy. 
 
 "We've got the battle of our lifetime ahead of us,” Ron Pollack, executive director of advocacy group Families USA, said the day after Donald Trump was elected on a pledge to repeal the Affordable Care Act, which now covers 22 million people. “We're going to have a huge number of organizations from all across the country that will participate in this effort." 
 
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 But their options are limited. They have enough votes to block a total repeal of the law on Day One of a Trump administration. But they can’t block Republicans from passing targeted legislation in the coming months, and Trump — like Obama before him — can pick up a pen as early as Jan. 20 and use executive powers to block, change or put on hold key elements of the massive, 6-year-old legislation. 
 
 The road to repeal is more complex than Trump acknowledged on the campaign trail. The law is baked into the health care system, touching every American’s life and a fifth of the economy. 
 
 But with the Republican sweep of both the executive and legislative branches, expectations for big and bold action are high. 
 
 "It's pretty high on our agenda, as you know," Senate Majority Leader Mitch McConnell said on Wednesday. "I would be shocked if we didn't move forward and keep our commitment to the American people." 
 
 Democratic aides on Capitol Hill said it was too early to have concrete plans but that defending Obamacare is a top goal. The law brought uninsurance rates to record lows, and many people have received financial help to get covered. 
 
 “Sen. Schumer and Senate Democrats are interested in ways to improve the Affordable Care Act. But we will fight tooth and nail against any attempt to repeal it,” a senior Senate Democratic aide told POLITICO, referring to incoming Minority Leader Chuck Schumer. 
 
 But Trump, if he chooses, could make his mark immediately. He could loosen requirements, for instance by exempting more people from the individual mandate to buy insurance. The new administration could also cut off funds for outreach and enrollment assistance for Obamacare plans, just at the peak busy days at the end of the 2017 sign-up season. 
 
 The Trump Justice Department could also stop fighting the lawsuit the Republican House brought against the Obama administration, seeking to shut off subsidies that help pay low-income people’s doctors bills. If the House wins, those payments would dry up — sticking the insurance plans with the bills. If the subsidies stop, insurance companies would have the right to drop out of the Obamacare markets almost immediately, which could lead to the collapse of the exchanges. 
 
 Or Trump could work with GOP lawmakers to siphon funding that was supposed to help insurers get through the first risky years of Obamacare — funds that congressional Republicans have already limited. 
 
 “You can change regulations almost immediately to give the power back to states to give them choice,” said Sen. John Barrasso (R-Wyo.), an orthopedic surgeon, who is likely to be a key Senate leader on Obamacare repeal. He was one of several lawmakers and Trump advisers who called for some kind of transition or phase-out period to help people who would be losing coverage. 
 
 Republicans can’t repeal the law straightaway because Democrats will still hold enough Senate seats to mount a filibuster. But over the longer term, Republicans can kill enough of the measure to make it essentially moot. And Trump could undermine the ACA in multiple ways upon taking office because the law gave so much discretion to the Health and Human Services secretary. 
 
 A Republican Congress could also siphon Obamacare funding to insurers. Lawmakers already blocked some payments meant to offset the financial risk the health plans took on in the uncertain new markets. That’s one reason the insurers raised premiums this year, to make up for anticipated payments that never materialized. 
 
 All that has rattled health care industry groups, who did not expect Trump’s triumph and who have spent the past six years adjusting to Obamacare. 
 
 “I’ve got clients freaking out a little bit. It’s just the unknown,” said one veteran health care lobbyist, noting that pre-Election Day briefings were typically dominated by gaming out a Clinton administration. 
 
 Whether through regulation or legislation, there are risks to taking down Obamacare. 
 
 Dismantling an exceedingly complex law that has become baked into the health care system would add uncertainty and frustration to the insurance companies running Obamacare plans. 
 
 “For the last four years, every problem of the health care system has been blamed on Obamacare,” said Tim Jost, a legal expert and strong supporter of the law. “From here on out it’s going to be blamed on Trumpcare — and we’ll see how that works out.” 
 
 Trump has provided few details about his health care replacement proposals. He has used some of the same phrases and big picture concepts as congressional Republicans, but with so little detail, it’s difficult to say how his ideas meld with those on the Hill. 
 
 “Anybody that says they know what’s going to happen now is smoking something excluded from Part D coverage,” said John Gorman, an insurance consultant. (Part D covers legal prescription drugs.) 
 
 Republicans may try to thread the needle between voter demands and massive health industry disruption by taking an early vote on Obamacare repeal — symbolic, given the Democratic filibuster — to show voters they will live up to their promise, and then build in time for a transition. 
 
 "I think the replacement, obviously, must come first, and it must be something that is very appealing and easy to understand,” Ben Carson, the retired neurosurgeon and top Trump ally, told POLITICO. “And then, only then, would you dismantle what's in place." 
 
 Ben Carson on Obamacare: " I think the replacement obviously must come first." | AP Photo 
 
 Republicans also have a longer-term path to permanently repeal several huge parts of the law through legislation. 
 
 Republicans did a test run of their legislative plan to repeal several huge parts of the law last year when the Senate passed repeal legislation through the complex budget reconciliation process, which requires only 51 votes and can’t be filibustered. That bill would have eliminated the ACA subsidies that help consumers buy insurance, Medicaid expansion and the medical device and Cadillac taxes. It would also eliminate the fines for the individual and employer mandates, rendering them moot. Obama vetoed the bill. 
 
 House Speaker Paul Ryan happily acknowledged that a similar bill would face a different fate next year. 
 
 "This Congress, this House majority, this Senate majority has already demonstrated and proven we're able to pass that legislation and put it on the president's desk. Problem is, President Obama vetoed it," Ryan said. "Now we have a President Trump who has promised to fix this." 
 
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 Dan Diamond contributed to this report. ||||| The meeting is at 9 a.m. in the Congressional Visitors Center auditorium. | Getty Obama to huddle with Hill Democrats on saving Obamacare 
 
 President Barack Obama will head to Capitol Hill Wednesday to meet with congressional Democrats about how to shield Obamacare from Republican efforts to dismantle it, a Capitol Hill source told POLITICO. 
 
 The meeting is at 9 a.m. in the Congressional Visitors Center auditorium and is for both House and Senate Democrats, according to a notice sent to members Friday morning. 
 
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 With Republican vowing to begin repealing Obamacare almost immediately when the 115th Congress convenes next week, Democratic lawmakers are immersed in strategy sessions on how to protect the nearly seven-year-old health care law. 
 
 Incoming Senate Minority Leader Chuck Schumer (D-N.Y.) has promised to stand firm against repeal efforts and subsequently, Republican efforts to replace the Affordable Care Act with a more conservative framework. And a conference call convened by House Democrats earlier this week focused largely on emphasizing the benefits of Obamacare, with House Minority Leader Nancy Pelosi (D-Calif.) noting that she sees parallels between the current situation and the 2005 effort by then-President George W. Bush to privatize Social Security, according to an aide on the call. 
 
 “The Affordable Care Act has been successful in meeting its goals of reducing cost, increasing access and improving quality of care,” Pelosi wrote to members in a “Dear Colleague” letter this week. 
 
 Democrats are also launching a broader health care offensive against Republicans that focuses not only on their push to repeal Obamacare but any prospective efforts from the GOP to overhaul Medicare and Medicaid. To that end, Democrats, led by Schumer, Pelosi and liberal firebrand Sen. Bernie Sanders (I-Vt.) — will host a so-called “day of action” on Jan. 15 that is meant to rev up grass roots support for shielding social safety net programs. 
 
 “Beginning in January, it is likely that Republican leaders in Congress will follow through on their threats to ram through a budget bill that will severely undermine the health care needs of the American people,” the three lawmakers wrote in a "Dear Colleague" letter circulated earlier this week. 
 
 Though most legislation generally needs 60 votes to advance in the Senate, Republicans can do away with significant portions of Obamacare with a simple majority by using a parliamentary move called “reconciliation,” which undercuts a filibuster. The GOP is also mulling a lengthy transition period for Obamacare repeal, meaning that the law would not actually be abolished for years — buying Republicans time to craft a replacement. 
 
 Still, if the pillars of Obamacare are successfully dismantled, moderate Democrats — particularly those senators up for reelection in 2018 — could come under considerable pressure to help Republicans replace the law and are already openly entertaining that option. 
 
 Incoming House Democratic Caucus Chairman Joe Crowley of New York said the meeting will likely include discussion of other policy matters in addition to Obamacare — such as the Dodd-Frank financial law and environmental issues. 
 
 “There are a myriad of issues he could address," Crowley said in an interview Friday. "As he retires from public office, we’re left to defend the advancements he’s made. Not only as a party, but as a people.” 
 
 Darren Samuelsohn contributed to this report. ||||| This is the web version of VoxCare, a daily newsletter from Vox on the latest twists and turns in America’s health care debate. Like what you’re reading? Sign up to get VoxCare in your inbox here. 
 
 The House of Representatives will vote on the American Health Care Act, the bill to repeal and replace Obamacare, on Thursday in the early afternoon. House Republicans are hurtling toward a vote on a bill that is disliked by most Americans, opposed by nearly every major health care group, and not yet scored by the Congressional Budget Office. 
 
 This is an unusual situation, and a puzzling one. Republicans will vote tomorrow for a health care bill without knowing how many people it covers or how much it would cost. They risk setting themselves up for embarrassment when the numbers actually do come out and don't look good. 
 
 As leadership scrambles to whip the votes for the American Health Care Act, it's worth stepping back to ask: What the heck is the rush? 
 
 The best explanation I've found comes from my colleague Andrew Prokop. When Republicans started this year, they had a strategy to move two big policy packages, one on health care and another on tax reform. There would only be two chances to use the budget reconciliation process that allows a bill to pass with only 51 Senate votes (for complex procedural reasons explained here), so each would get one shot. 
 
 Health reform would go first, they thought, because it would be simpler. It was a legislative strategy built when the Republican health care plan looked markedly different: 
 
 They thought it would be legislatively easier to write an Obamacare repeal bill than tax reform, because they intended to put off the hard work of creating an actual replacement for Obamacare until later. This was the “repeal and delay” strategy — pass a quick repeal, set it to go into effect in a few years, and write the replacement in the meantime. But then GOP leaders encountered a problem. Their members, in both the House and the Senate, turned out to really hate the “repeal and delay” strategy, because it meant getting rid of Obamacare and its benefits without the “replacement” the party had long promised they’d offer being ready. 
 
 Republicans want to move quickly on health care so they can fit in tax reform too, another immense and complex policy lift. 
 
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 Adding to that pressure, it's also the case that this current frenzy began as Trump was nearing his 100th day as president and pressuring Congress to schedule a vote. Although the 100-day mark has come and gone, some of that residual momentum seems to have hung around. 
 
 This all explains why, in general, there is a desire to move relatively quickly. 
 
 The part that Republicans haven't explained: Why move so quickly that they don't get a score from the Congressional Budget Office? 
 
 A legislator deciding whether or not to support the American Health Care Act would likely wonder what the bill actually does. This is the role CBO has traditionally played, providing nonpartisan estimates of who would gain coverage, who would lose it, and how much the whole thing would cost. 
 
 The whole point of CBO scoring is to figure this out before you decide whether a piece of legislation is good or bad. This also gives legislators some space to make changes to parts of a bill that don't seem to work. CBO scores are meant to be a tool for legislators, a way to game out the consequences — both politically and policy-wise — of moving laws forward. 
 
 It's notable that we haven't heard one member of Congress say, "I like the idea of this bill, but I'll wait until we see the CBO score to make up my mind." 
 
 But so far, the CBO score has been treated as unnecessary — certainly nice to have, but not a prerequisite for holding a floor vote. Here's how Rep. Fred Upton (R-MI) put it earlier today to a reporter: 
 
 Upton said he'd like to see a CBO score, like most members say, but apparently it's not a condition for him voting for the bill, which, ah. — Matt Fuller (@MEPFuller) May 3, 2017 
 
 There are very few people telling Republican legislators at this point that the American Health Care Act is a good bill. Basically every health care interest group you can think of – hospitals, doctors, insurers, patients — don't support it. The most recent polling data finds most voters don't like it either. There is not a CBO score that suggests this bill achieves House Republicans' objectives. 
 
 At this point, Republicans seem more concerned with moving something out of their chamber than they do with what that something is. That is a risky and potentially embarrassing move. The CBO score will come out sooner or later, and Republicans might be faced with defending a bill they don't like much at all. 
 
 Meanwhile, in Iowa: insurer threatens to leave 94 of 99 counties with no Obamacare insurer 
 
 The health insurance plan Medica announced Wednesday that it was considering pulling out of Iowa's insurance marketplace. It is the only insurer signed up to sell coverage in all the dark pink areas of the map below, from Margot Sanger-Katz at the New York Times: 
 
 In a statement, Medica said the uncertainty in Washington makes it difficult to commit to sticking with the marketplaces in 2018: 
 
 Without swift action by the state or Congress to provide stability to Iowa’s individual insurance market, Medica will not be able to serve the citizens of Iowa in the manner and breadth that we do today. We are examining the potential of limited offerings, but our ability to stay in the Iowa insurance market in any capacity is in question at this point. 
 
 It's hard to know how much of a bellwether Medica is for the rest of the Obamacare marketplaces. On the one hand, all insurers are frustrated that Congress likely won't be appropriating funding for the cost-sharing reduction subsidies. 
 
 On the other hand, Iowa seems to be a bit of an exceptional situation. There is one patient in the marketplace who reportedly has $1 million in monthly claims (you can read more about the situation here). This has made the entire state an undesirable market for health plans, which know that if they're the last man standing, they will end up with that extremely high-cost patient. 
 
 Kliff’s Notes 
 
 Your daily top health care reads, with research help from Caitlin Davis 
 
 Today's top news 
 
 "Key Republicans Long, Upton say they now support Obamacare repeal with more money for pre-existing conditions" : “Two key Republican lawmakers say that they will support a bill to repeal and replace Obamacare after changes were proposed to provide additional funds for people with pre-existing conditions. Republican Reps. Fred Upton of Michigan and Billy Long of Missouri announced their decision to reporters outside the White House Wednesday after meeting with President Trump about the legislation.” —Kimberly Leonard, Washington Examiner 
 
 “Two key Republican lawmakers say that they will support a bill to repeal and replace Obamacare after changes were proposed to provide additional funds for people with pre-existing conditions. Republican Reps. Fred Upton of Michigan and Billy Long of Missouri announced their decision to reporters outside the White House Wednesday after meeting with President Trump about the legislation.” —Kimberly Leonard, Washington Examiner "No good GOP options if Obamacare repeal fails" : “If their latest Obamacare repeal efforts fail, Republicans really only have a few options. And each means political peril for President Donald Trump and Republican congressional leaders. House members made progress Wednesday on the repeal and replacement bill — but there are still many hurdles, including overcoming some of the same challenges in bringing together conservatives and moderates if the bill reaches the Senate.” —Adam Cancryn and Paul Demko, Politico 
 
 “If their latest Obamacare repeal efforts fail, Republicans really only have a few options. And each means political peril for President Donald Trump and Republican congressional leaders. House members made progress Wednesday on the repeal and replacement bill — but there are still many hurdles, including overcoming some of the same challenges in bringing together conservatives and moderates if the bill reaches the Senate.” —Adam Cancryn and Paul Demko, Politico "Insurer Aetna Posts Loss, Evaluates Obamacare Exposure": “Aetna Inc reported a quarterly net loss on Tuesday related to costs from its failed acquisition of Humana Inc and said it will cut exposure to money-losing Obamacare coverage in 2018. Like other U.S.-based health insurers including Anthem Inc and Molina Healthcare Corp, Aetna faces deadlines to file 2018 plans but is uncertain about components of premium rates such as the continuation of government subsidies and the mandate for Americans to have insurance.” —Reuters 
 
 Analysis and longer reads 
 
 "Why Democrats secretly want an Obamacare repeal vote" : “Democrats don’t actually want the law repealed. Under their dream scenario, House GOP leaders would muscle through their controversial health care bill only to watch it die a long, painful death in the Senate, where it has already received a lukewarm reception from Republicans. Obamacare would stay intact while the House Republicans who voted to gut the law have a big shiny target on their back heading into the 2018 midterms.” —Heather Caygle, Politico 
 
 “Democrats don’t actually want the law repealed. Under their dream scenario, House GOP leaders would muscle through their controversial health care bill only to watch it die a long, painful death in the Senate, where it has already received a lukewarm reception from Republicans. Obamacare would stay intact while the House Republicans who voted to gut the law have a big shiny target on their back heading into the 2018 midterms.” —Heather Caygle, Politico "Personal Tragedy Drives Deal-Making GOP Congressman on Health Care": “Since the Republicans' failed attempt to repeal and replace the Affordable Care Act, [Rep. Tom] MacArthur has nearly single-handedly breathed new life into an effort that could culminate in a vote on the GOP measure this week. But while the fight over health care has played out as political high drama in the halls of power in Washington, for MacArthur it's also a personal battle stemming from the loss of his 11-year-old daughter nearly two decades ago.” —Leigh Ann Caldwell, NBC 
 
 "As patients take hospital bill issues public, hospitals take stock of their practices": “Recently, four hospital systems in Colorado — Centura Health, Health One, SCL Health and UCHealth — found themselves on the defensive after 9News, based in Kusa, ran a piece that was critical of their billing practices. The news station had invited viewers to email copies of their medical bills to give reporters an idea of what consumers were dealing with when it came to their bills. The station then invited the four health systems to their newsroom to answer on-air questions based on patients' complaints.” —Jeff Lagasse, Healthcare Finance
– President Obama looks genuinely worried about the fate of ObamaCare: He will meet Wednesday morning with House and Senate Democrats to plot strategy on how to prevent Republicans from killing it, reports Politico. The problem for Democrats is that there may not be much they can do in the near future. As both Politico and the Hill point out, Republicans can pass a repeal measure without any Democratic support through a legislative maneuver known as a reconciliation vote. The procedure requires only a simple majority, not 60 votes, and the GOP has promised to move on it immediately in the new year. The caveat is that, assuming repeal passes, Republicans are expected to delay the actual dismantling of the law for quite a while to give them time to craft a replacement. That delay could be as long as three years, reports Time. So what can Democrats do? For one thing, raise political pressure. Senate Democratic leader Chuck Schumer and his House counterpart, Nancy Pelosi, plan rallies next month, and ObamaCare advocates promise to flood the airwaves with ads in states such as Arizona and Nevada, where they think GOP senators might be swayed. The idea is not only to try to block repeal itself but to keep as much of the law in place as possible if repeal passes. President-elect Trump, for example, has said he would like to keep parts of ObamaCare intact, notably protections for those with pre-existing conditions. The White House said this month that 6.4 million people had signed up for ObamaCare before a Dec. 19 deadline, up 400,000 from the previous year.