“This is the chance. This is a once-in-a-lifetime opportunity,” said the speaker, roving the stage with a wireless mic, gesturing at both the audience in front of him and the PowerPoint presentation behind him.

TED Talk? Late-night infomercial? Nope — it was House Speaker Paul Ryan, making a hard pitch for his health care plan after a week of loud conservative criticism.

After listening to conservative groups like the Club For Growth blast the bill as a “warmed-over substitute for government-run health care,” Ryan went on offense, saying this is just the first step of an ongoing overhaul of the health system.

The bill, drafted by Ryan and other House Republican leaders, cleared a key hurdle Thursday, passing two House committees after marathon markup sessions. But many members from the Tea Party wing are upset that it keeps too much of the Affordable Care Act in place and effectively replaces the law’s signature tax with a heavy surcharge assessed to people who forgo health insurance.

“There are only so many things you can do in that bill because of Senate floor rules, reconciliation,” Ryan said. “You can’t put everything you want in that legislation, because if you did it would be filibustered, and you couldn’t even bring it up for a vote in the Senate.”

Then Ryan applied some public pressure. “We as Republicans have been waiting seven years to do this. We as Republicans, who fought the creation of [Obamacare], and accurately predicted it would not work, ran for office in 2010, in 2012, in 2014, in 2016, on a promise that if given the ability we would repeal and replace this law.

“This is the closest we will ever get to repealing and replacing Obamacare. The time is here; the time is now. This is the moment,” said Ryan, summing up the situation as a “binary choice” for Republicans: Ditch Obamacare, or keep it.

Ryan’s pitch comes at a time when many key trade groups are voicing major concerns about the repeal. The American Medical Association sent a letter to lawmakers bemoaning an “expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.”

The American Hospital Association urged Republican leaders to wait until the Congressional Budget Office analyzes the bill.

That’s something Democrats are homing in on. “Look: No one likes this bill,” said Senate Minority Leader Chuck Schumer. “Hospitals, doctors, governors. Conservatives, liberals, nonpartisan groups. And most of all, the people who would no longer have affordable health care.

“We Democrats are here today to tell our Republican friends, turn back. Drop this irresponsible plan.”

Currently, Ryan and other Republican leaders don’t need Democrats to pass the bill. They can afford to ignore Schumer.

But with just a two-vote margin in the Senate, they can’t ignore Republican senators. So it was notable when Arkansas Sen. Tom Cotton tweeted that the House bill won’t be able to win a Senate majority. “To my friends in House: pause, start over. Get it right, don’t get it fast.”

Florida Sen. Marco Rubio voiced similar worries to the New York Times. Ryan and Senate Majority Leader Mitch McConnell want the bill on President Trump’s desk by the end of April. “I think if that’s the approach they take, they won’t have the votes in the Senate,” Rubio warned.

That’s why Republican leaders have now pulled out all the stops in their attempts to get rank-and-file members on board. As Schumer and other Democrats were blasting the bill outside the Senate on Thursday morning, they had to raise their voices at one point to speak over sirens.

It was Vice President Pence’s motorcade driving by. He was back on Capitol Hill for the second time this week, meeting with fellow Republicans to talk and pitch the health care bill.

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The Republican health care overhaul working its way through the House is opposed by Democrats and by many Republican conservatives. It’s none too popular with the people on the front lines of health care, either — including doctors, nurses and hospitals.

The chief medical officer of Medicaid, Dr. Andrey Ostrovsky, tweeted out his opposition on Wednesday. “Despite political messaging from others at HHS, I align with the experts … in opposition to #AHCA,” the career staffer said.

Ostrovsky, who has been in his current job since September, has received praise from former Obama administration officials for speaking out.

Former Medicare and Medicaid chief Andy Slavitt called Ostrovsky a “hero.”

Trump’s Health and Human Services secretary, Tom Price, has been out front with other Republican leaders pitching the new bill. In a press briefing on Wednesday, he said the administration will be looking at Affordable Care Act regulations “and make certain that if they help patients, then we need to continue them. If they harm patients or increase costs, then obviously they need to be addressed.”

The organizations Ostrovsky cited in his tweet that have voiced concerns are the American Academy of Family Physicians, the American Academy of Pediatrics and the American Medical Association.

The AMA sent a letter to congressional leaders saying it was unable to support the GOP bill largely due to the “expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.”

Among other things, the AMA cited the proposed rollback of Medicaid expansions that happened under the Affordable Care Act, which the group called “highly successful in providing coverage for lower income individuals”; the proposed repeal of the Prevention and Public Health Fund, also established by Obamacare; and provisions targeting Planned Parenthood.

In a similar letter, the American Nurses Association said the Republican plan “threatens health care affordability, access, and delivery for individuals across the nation.” It points to changes the bill would make to Medicaid and says the measure “restricts million of women from access to critical health services.” The ANA says the proposed changes “in no way will improve care for the American people.”

The American Hospital Association also weighed in, pointing out the Congressional Budget Office has yet to provide a cost estimate for the measure or say how it would change coverage levels. Without such analysis and “needed transparency,” the group said, Congress “should wait” before proceeding.

It also points to the proposed restructuring of Medicaid, saying it will “have the effect of making significant reductions in a program that provides services to our most vulnerable populations, and already pays providers significantly less than the cost of providing care.”

The opposition to the GOP plan from health care groups, who say its provisions need to be more generous, puts GOP leaders in a quandary. On the other side of the equation, conservative House members are opposing the measure because they believe it is too generous and doesn’t go far enough to repeal subsidies in the Affordable Care Act.

The bill’s authors have responded to the criticism. “There’s a pretty big the medical-industrial complex in America,” Rep. Greg Walden of Oregon, chairman of the House Energy and Commerce Committee, told reporters. “And when you touch it, I’ve discovered, it touches back.”

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With the Republicans’ new health care plan under attack from all sides, Steve Inskeep talks to one of the architects of the Affordable Care Act, Zeke Emanuel, about the possibility of compromise.

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For years, congressional Democrats have tried to pass legislation to allow Medicare to negotiate prescription drug prices for millions of beneficiaries.

Now, they believe they have a not-so-secret weapon: President Donald J. Trump.

On Wednesday, U.S. Reps. Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) met privately for about an hour with Trump and his newly appointed HHS secretary, Tom Price, to discuss ways to combat high drug prices. They were joined by Dr. Redonda Miller, president of Johns Hopkins Hospital.

The Congressmen pitched a House bill that would expand the federal government’s ability to negotiate drug prices, and they left feeling optimistic about what Trump will do.

“He made it clear to us that he wanted to do something,” Cummings said, characterizing Trump as “aware of the problem” and “enthusiastic.” Cummings is ranking member of the House Committee on Oversight and Government Reform.

Trump tweeted the day before his meeting with Cummings and Welch that he is “working on a new system where there will be competition” in the drug industry.

After the meeting, the president relayed his desire to work “in a bipartisan fashion to ensure prescription drug prices are more affordable for all Americans.”

Allowing the federal government to negotiate drug prices is not a new idea, but Cummings and Welch painted a picture Wednesday of a political landscape that is ripe for change. They said they have a president who “gets it.”

And, Welch said, “the price is starting to kill us, we just can’t afford it.”

The lawmakers said they handed Trump and Price the most recent draft of the bill for their review and to make comments. Cummings said he hopes to file the bill in two weeks.

A summary posted on the House committee website, said the proposed legislation would enable HHS secretary to negotiate lower prices with drug manufacturers under Medicare Part D, which provides coverage for prescription drugs bought at pharmacies.

An estimated 41 million Americans are covered by Part D. The drug benefit is provided through private insurers who each have their own formulary (a list of allowed drugs) and generally use pharmacy benefit managers for drug purchasing. The latest proposal would direct the HHS Secretary to establish a formulary.

The formulary would be used to “leverage” the purchasing power of the government, according to the summary.

Douglas Holtz-Eakin, a former director of the Congressional Budget Office and now president of the American Action Forum, said the idea of lowering prices through Medicare Part D negotiations is “completely unrealistic.”

Holtz-Eakin points out that insurers are already used to managing health care for beneficiaries and there are formularies in those plans. Adding into the law that the HHS Secretary should be part of the negotiations merely adds a “bully pulpit,” he said.

“The problem with the negotiation in Part D is not a political, partisan problem — it’s that it won’t work,” said Holtz-Eakin, adding that the Medicare Part D program is already holding prescription drug costs down because of the negotiating ability of the drug plans.

Trump himself, though, has long embraced the idea of Medicare negotiating drug prices. On the campaign trail in January 2016, he reportedly told a crowd in New Hampshire that Medicare could save a huge amount of money by getting discounts, as the biggest buyer of prescription drugs.

“We don’t do it,” Trump said that day, according to the Associated Press. “Why? Because of the drug companies.”

PhRMA, the drug industry’s powerful lobbying group, says price negotiation is already happening.

“Large, powerful purchasers negotiate discounts and rebates directly with manufacturers, saving money for both beneficiaries and taxpayers,” PhRMA’s Holly Campbell said Wednesday, in an email.

She pointed to a Congressional Budget Office report that said HHS would not be able to negotiate lower prices than already exist.

Trump met with pharmaceutical executives in January and told them, “We have to get prices down for a lot of reasons. We have no choice.”

Umer Raffat, a research analyst at Evercore ISI, said the industry felt less jittery after that meeting. They walked away understanding that President Trump wants to “promote innovation” while addressing prices.

Sarah Jane Tribbleis a senior correspondent atKaiser Health News, an editorially independent newsroom that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

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As Congress begins the process of amending the Republican health care bill, listeners tell us how the proposed plan will affect their insurance costs.

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NPR’s Robert Siegel talks to David Certner, legislative policy director for the AARP, about the House Republicans’ heath care reform proposal.

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Two House committees are debating Wednesday on a Republican to overhaul the Affordable Care Act, also known as Obamacare.

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House Speaker Paul Ryan from Wisconsin has been complaining about the Affordable Care Act (aka Obamacare) for so long that his list of grievances sound like a refrain of some pop song.

“Obamacare is collapsing,” he said on Feb. 28. “The Democrats got too far ahead on their ideology and they gave us a system where government runs health care. They gave us a system where costs went up, not down. They gave us a system where choices went away. They gave us a system where people lost the plans they liked, they chose.”

And Ryan’s not the only one. Republicans in Congress have spent the last several years detailing what is wrong with the ACA. And in every election since it passed, nearly every Republican candidate, including President Donald Trump, has vowed to get rid of the law and put something better in its place.

On Monday evening, House Republicans finally released their own health care proposal. It would replace Obamacare’s mandate to buy insurance and his subsidies to bring down the cost with a fixed refundable tax credit that people can use to buy coverage. Nobody’s required to have a health plan. But if you don’t get covered at the outset, you’ll pay a penalty to buy it later.

So does it fix the problems Republicans have laid out? Likely not.

Let’s start with the collapsing insurance market.

“It’s debatable whether the market is imploding or not,” says Cynthia Cox, Associate Director of the Program for the Study of Health Reform and Private Insurance at the Kaiser Family Foundation.

But if you agree that it’s collapsing?

“On one hand they’re getting rid of the individual mandate [for most people to buy insurance], and that would have the effect of destabilizing the market and raising premiums,” Cox says.

And the penalty for allowing a gap in your health insurance coverage could help, or it could make it worse, she says.

The penalty could be “a disincentive for healthy people to sign up,” she says.

That’s the central challenge both approaches face. A healthy market needs a lot of healthy people so that premiums are spread across a broad population to care for sick people. Without that, the market struggles to keep costs low and choices high.

Obamacare’s markets have been struggling, no doubt. Several insurance companies have dropped out, leaving some states and counties with only one company offering plans. At the same time, premiums have risen in many markets. Last year, premiums rose an average 22 percent — though individual cost increases varied because federal subsidies for many people rose in tandem with premiums.

Ryan says he wants consumers to have more choices and lower costs.

“Instead of fewer choices, we want our health care system to be truly competitive. Insurers should compete for your business and treat you fairly,” he said on Feb. 22. “All of this will lower cost and end the annual sticker shock of higher premiums.”

Will his plan offer more choices?

Not necessarily, says Paul Howard, a senior fellow at the conservative Manhattan Institute.

“There’s not enough flexibility from the insurers point of view to offer lower cost plans,” he said.

That’s because Republicans are hamstrung by politics, he says. They can’t repeal the Affordable Care Act outright without the help of Democrats, which they won’t get. So in order to get a bill through, Congressional rules say they have to limit it to matters that deal with taxes or the budget.

Which means all the benefits that Obamcare says have to be included in a health insurance policy remain. And that means insurance companies can’t offer cheap health plans.

Which brings up Ryan’s other goal: lowering costs.

“I don’t see it being abundantly clear that premiums will be significantly lower under this bill than they are in the Affordable Care Act,” says Cox of Kaiser. “And there is evidence the out-of-pocket costs could go up,” she says.

That’s because Obamacare offers subsidies to cover the deductibles and co-payments for lower-income people. The Ryan plan offers a fixed tax credit — between $2,000 and $4,000 depending on age — that would likely lead many people to buy health plans they have to shell out a lot of money for up front, called “high deductible plans.”

Cox’s analysis shows that wealthier people get more help from the new Republican plan while lower income people benefit more from Obamacare.

Republicans are hamstrung in part by the fact that they can’t repeal the Affordable Care Act in one go and fully replace it with their own vision.

Even if the bill did meet Paul Ryan’s goals, it certainly doesn’t fulfill President Trump’s campaign promises.

“Everybody’s got to be covered,” he said in an interview with 60 Minutesin 2015. “This is an un-Republican thing for me to say, because a lot of times they say, ‘No, no, the lower 25 percent, they can’t afford private.’ But I am going to take care of everybody.” He repeated that goal this past January in an interview with The Washington Post.

As it turns out, the Affordable Care Act didn’t cover everybody. And early analyses of the Ryan proposal suggest his plan could reach even fewer people.

A report from Avalere Health and McKinsey estimated that 30 percent of those in the individual health insurance market could drop out if the current subsidies were swapped out for the age-based tax credits.

Howard of the Manhattan Institute worries that people who are now heavily subsidized will fall away.

“I would have some concerns about those low-income folks dropping out of the market, and concerns about whether or not that 30 percent surcharge is going to keep the younger population in the market,” he said.

Stay tuned. The process of moving the bill through Congress starts Wednesday in the House committees with jurisdiction over health care.

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A difficult part of implementing a new health care law is providing health insurance to the sick and underserved. Steve Inskeep talks with MIT economist and Obamacare architect Jonathan Gruber.

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Many Tea Party Republicans are raising objections to the new GOP-written health care bill, but Speaker Paul Ryan says he’s guaranteeing it will pass the House in the coming weeks.

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