By Jonathan D. Salant | NJ Advance Media for NJ.com

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So what happens now?

House Republicans succeeded on their second try in repealing and replacing the Affordable Care Act with legislation that the Congressional Budget Office said would leave 24 million more Americans without coverage by 2026.

The 217-213 vote sends the bill to the Senate, whose members have their own concerns and priorities.

“The bill faces substantial changes in the U.S. Senate, further guaranteeing that the final product will have to be a compromise between the two chambers," said Rep. Leonard Lance (R-7th Dist.).

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Senate Majority Leader Mitch McConnell (R-Ky.), flanked by Sens. Cory Gardner (R-Colo.), John Barrasso (R-Wyo.), and John Thune (R-S.D.), after a weekly policy luncheon at the Capitol. (Aaron P. Bernstein | Getty Images)

Like their House counterparts, Senate Republicans will be able to shut Democrats out of any efforts to write health care legislation since they need only a majority, not a filibuster-proof 60 votes, to pass their bill.

But also like the House, individual Republicans have their own priorities and may be willing to deviate from the party line if those concerns are not addressed. For example, some represent states that have expanded Medicaid, and may not support the House Republican provision that would make new recipients ineligible for additional federal funding after 2020.

"Let's see what they do," said Rep. Tom Cole (R-Okla.), a senior member of the House GOP conference. "It will be interesting to watch them for a while. They've gotten to watch us for a hundred-plus days. Now we'll watch them."

The vote also means:

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President Donald Trump congratulates House Speaker Paul Ryan (R-Wis.) at the White House after House Republicans passed legislation to repeal the Affordable Care Act. (Mark Wilson | Getty Images)

A boost for Trump

Most congressional Republicans shunned Donald Trump when he announced his candidacy. They skipped his nominating convention and kept their distance after he became their party's nominee.

No longer.

"We just have developed a bond," Trump said at a Rose Garden rally to celebrate the House Republican vote to repeal the health care law. "This has really brought the Republican Party together."

Cole said Trump was learning how to win friends and influence lawmakers, which can only help him going forward in trying to get his priorities through Congress.

"It's been good for us because we've gotten to know him better and I think it's been good for him," Cole said. "He's starting to get the sense of the institution, the players, the members very individually. Over time, that kind of engagement is very important."

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Competing pressures lie ahead

While conservative groups dropped their opposition to the legislation once the Freedom Caucus signed on, they by no means think the House Republican bill is good enough.

"While we're pleased to see the American Health Care Act move forward, allowing the House the chance to move on to other priorities such as fundamental tax reform, this bill falls short of Republicans' promises to fully repeal Obamacare," FreedomWorks President Adam Brandon said. "No one should kid themselves into believing otherwise."

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Doctors, nurses, hospitals and groups representing patients all think the House bill isn't good at all.

They represent a potent force: Health industry employees and executives contributed almost $200 million to federal candidates for the 2016 elections and spent $515 million last year to lobby the federal government, according to the Center for Responsive Politics.

"America’s hospitals and health systems are deeply disappointed in the House passage of the AHCA because it will jeopardize health coverage for millions of Americans," said Rick Pollack, president and chief executive of the American Hospital Association. "We urge the Senate to restart and reset the discussion in a manner that provides coverage to those who need it and ensures that the most vulnerable are not left behind."

Even the health insurance industry had problems with the bill.

"The American Health Care Act needs important improvements to better protect low- and moderate-income families who rely on Medicaid or buy their own coverage," said Marilyn Tavenner, president and chief executive of America’s Health Insurance Plans, the industry's Washington trade association.

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N.J.'s senators may sit on the sidelines

Under the precedent set when Republicans were in the minority, significant legislation usually needs 60 votes to pass the Senate. With only 52 Republicans, that means eight Democrats must go along.

But the health care repeal bill was drafted using a parliamentary procedure known as reconciliation, which prevents a filibuster and allows legislation to pass by majority vote.

The problem is that there are limits as what legislation debated under reconciliation can contain, so many provisions Republicans want may have to go through the regular legislative process, giving Democrats a chance to weigh in and block the most onerous provisions.

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If I'm more than mildly nauseous about GOP's cruel plan to strip healthcare from >24 million, is that a pre-existing condition? #VoteNoAHCA — Senator Bob Menendez (@SenatorMenendez) May 4, 2017

Both senators had harsh words for the GOP health care bill and said they would do what they could to kill it.

"This will cost American lives if it ever becomes law," U.S. Sen. Cory Booker (D-N.J.) said on MSNBC. "This will mean death, pain and suffering to people's families."

U.S. Sen. Robert Menendez (D-N.J.) suggested the Republicans were motivated by their antipathy toward President Barack Obama.

“I cannot fathom what moral compass guides these representatives to treat their own constituents so cruelly, other than hatred towards a president who is no longer in office," he said.

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Rep. Tom MacArthur (R-3rd Dist.) speaks at the White House celebration of the Affordable Care Act repeal vote. (Jonathan D. Salant | NJ Advance Media for NJ.com)

MacArthur's future could be bright

Sophomore congressmen usually don't play as central a role in major policy debates as Rep. Tom MacArthur (R-3rd Dist.). Though he co-chairs the Tuesday Group of more moderate Republicans, he crafted a compromise that won the support of the Freedom Caucus, which represents the most conservative members of the House GOP caucus.

No matter how much Trump or House Speaker Paul Ryan (R-Wis.) cajoled lawmakers, it was MacArthur's amendment that resurrected the effort to pass a repeal bill, and his fellow Republicans are sure to remember that the next time a position opens up on a top congressional committee or in leadership.

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My statement on the passage of the #AHCA: https://t.co/3EQR0W4uYb — Archive: Tom MacArthur (@RepTomMacArthur) May 4, 2017

First, though, MacArthur has to win re-election next year, and his high-profile support of the Republican repeal bill ensures a target on his back in 2018.

The Democratic Congressional Campaign Committee on Thursday began running digital ads in 30 GOP-held districts, including MacArthur's.

“Kicking 24 million people off their health care insurance, increasing costs, slapping an age tax on folks above 50 and destroying protections for people with pre-existing conditions will go down in infamy as one of the most heartless acts ever passed through Congress,” DCCC spokesman Tyler Law said.

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Protesters outside Rep. Rodney Frelinghuysen's Morristown office. (Aristide Economopoulos | NJ Advance Media for NJ.com)

Where will Frelinghuysen's U-turn lead to?

Rep. Rodney Frelinghuysen's original decision to oppose the original health care bill put him at odds with House Republican leaders who had elevated him to the Appropriations Committee chairmanship.

"It is hard to say no, but sometimes you have to do what's right for your constituents," said ex-Rep. James Walsh (D-N.Y.) , a former Appropriations subcommittee chairman. "And leadership understands that."

This time Frelinghuysen (R-11th Dist.) reversed course and voted yes even as demonstrators assembled outside his Morristown office and urged him to remain opposed to the legislation.

He's also on the DCCC target list, representing a district where Trump received less than 50 percent of the vote last fall.

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.@USRepRodney, you said the last version of the AHCA was unacceptable. This version is worse. Please represent your constituents + vote no. pic.twitter.com/bvDRV6QmEa — NJ 11th for Change (@nj11forchange) May 4, 2017

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President Donald Trump congratulates House Republicans in the Rose Garden of the White House. (Mark Wilson | Getty Images)

Building momentum for tax cuts

At a victory celebration at the White House, Trump vowed to pivot to taxes next. His proposals would sharply reduce taxes for wealthy Americans like himself, while offering no specifics on how he will help lower- and middle-income taxpayers.

Those tax cuts would be in addition to the hundreds of billions of dollars in reductions that House Republicans already voted to give corporations and the rich in the health care repeal bill.

It remains to be seen whether House and Senate Republicans will be willing to work with congressional Democrats to overhaul the tax code. They went out of their way to ensure that Democrats would be excluded from the health care repeal efforts.

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Looking ahead to 2018

Just as anger over the original Affordable Care Act helped propel Republicans to victory in the 2010 midterm elections, Democrats are looking for the same boost in 2018.

At least four Democrats already have filed to run against Lance, who represents one of just 23 Republican-held congressional districts carried by Democrat Hillary Clinton. He already has faced DCCC attack ads.

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Only 17 percent of Americans supported the Republicans' efforts to repeal and replace the health care law, and that was before the GOP took steps that independent health care experts said would weaken protections for those with pre-existing conditions.

Still, voting to repeal the health care law was crucial to Republicans' chances next year, especially since they've promised to do for years.

"The Democratic base is whipped up, aroused," said Cole, a former chairman of the National Republican Congressional Committee. "Your best defense is having a Republican base that is similarly energized. You can't break your promise to them on something this basic and think they're going to be very enthusiastic about coming out."

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Recent stories about the House Republican repeal effort

N.J.'s Frelinghuysen changes stance and votes to repeal Obamacare

House Republicans repeal Obamacare in win for Trump

Meet Tom MacArthur: 9 things to know about N.J. lawmaker at center of health care bill

The 1 issue that will decide whether Obamacare lives or dies

President Trump spent Sunday talking about Obamacare. Here's what he got wrong.

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Jonathan D. Salant may be reached at jsalant@njadvancemedia.com. Follow him on Twitter @JDSalant or on Facebook. Find NJ.com Politics on Facebook.