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."


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 straight away 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 H ealth and H uman S ervices 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.