WASHINGTON, Feb. 1, 2017 - President Donald Trump has set a high bar for Congress when it comes to health care: “insurance for everybody,” including people with pre-existing conditions, at “much lower” cost. And he wants Congress to act fast, at the same time that lawmakers repeal the Affordable Care Act (ACA), as Obamacare is formally known. “We have to take care of the American people immediately, so we can’t wait,” he told Republican lawmakers at their retreat last week in Philadelphia.

Donald TrumpRepublicans say they plan to have legislation on the House floor before April. It’s not at all clear what will be included, but there is expected to be a budget reconciliation measure that doesn’t require 60 votes to pass the Senate. The fact that the measure would be filibuster-proof is critical since Republicans only control 52 votes and Majority Leader Mitch McConnell said he doesn’t expect any Democratic support.

A reconciliation measure would allow Republicans to change much of the ACA – but not all – because such bills must be limited to provisions of the law that have budget implications. A reconciliation bill that Congress passed in 2016 would have repealed the individual mandate, the Medicaid expansion and the premium subsidies but it didn’t provide a replacement. That measure never had a chance of becoming law, since lawmakers knew that then-President Obama would veto it, as he did.

This year, the stakes are far higher. There is fear that repealing the ACA without a replacement plan could destabilize the individual insurance market. And, GOP lawmakers are facing the reality of meeting the high demands of Trump – and many of their constituents – to lower the cost of insurance while insuring that no one loses protection. There are even divisions, which became public because of a leaked tape of the Republican retreat, over whether to use the legislation to defund Planned Parenthood.

Idaho Republican Sen. Jim Risch, a former governor, described the April deadline that GOP leaders have informally agreed to as “aspirational.”

Obamacare “is 3,000 pages of legislation, (and) thousands of pages of regulations on arguably the most complex sector of our economy, on the most personal matter of our economy,” he said. “To say we’re going to walk in one day and redo this thing I think is overly ambitious, overly optimistic. People are going to have to be patient.”

Republicans do not appear to be anywhere close to agreeing on a replacement plan or what will happen with existing Obamacare policies.

Rep. Kristi Noem, a South Dakota Republican on the House Ways and Means Committee, says that there will be some transition period for people with Obamacare. “We’re going to have an off ramp that everybody doesn’t get kicked off the plans that they have today. It will sustain them until that marketplace can react and give them more opportunities into the future,” she said.

One idea for a replacement plan that is being floated is to allow states to choose whether to stay with Obamacare or enact their own approaches, using the existing federal subsidies and Medicaid expansion funding. Republican Sens. Bill Cassidy of Louisiana and Susan Collins of Maine proposed that compromise as a way to ease passage of the legislation in the Senate.

“Republicans think that if you like your insurance, you should keep it, and we mean it. So we give states the option,” said Cassidy, a doctor whose wife is a retired surgeon.

But Noem and other GOP critics say they don’t want to leave Obamacare intact anywhere, and Democrats don’t like the Cassidy-Collins plan because they say that it could harm coverage in states that leave Obamacare.

The Ways and Means Committee continues working on a concept the GOP leadership unveiled last year called a “health care backpack.” People who don’t have insurance through their jobs or access to Medicaid and Medicare would receive at the beginning of each month a refundable tax credit to buy individual policies, which would theoretically be cheaper than they are now, once the ACA is repealed.

One of the new policy ideas Republicans are considering that could appeal to farmers and rural families is to allow individuals to buy into insurance pools operated by organizations such as farm groups. Those could cover 10,000 to 20,000 policyholders, Noem said.

The other challenge for Republicans is their crowded agenda for this year. It includes a sweeping tax reform bill; funding measures for both fiscal 2017 and 2018; a supplemental appropriations bill to fund Trump’s border wall, a massive infrastructure initiative that is a top priority for Trump; and Senate confirmation votes for Trump’s nominees. (Some 1,200 presidential appointments across the government require Senate approval.)

The tax reform legislation itself could prove to be every bit as heavy a lift for Republicans as health care reform. The GOP leadership’s goal is to have a tax plan on the House floor before the August recess, using a second budget reconciliation measure.

Trump told lawmakers he wants them to pass “bold tax reform that massively lowers taxes for our middle class.” But the GOP plan hinges on a revenue-raising border adjustment tax that would offset the cost of slashing personal and corporate rates and to provide other benefits, including repealing the estate tax and allowing full expensing of capital investments.

However, the brouhaha that erupted last week when the White House suggested using the border tax to pay for the U.S.-Mexico wall shows the controversy that’s likely to surround the tax plan once it gets more public attention.

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Still, House Speaker Paul Ryan in particular has shown little public sign of backing down on any of the GOP agenda and has even said Republicans are looking for money to fund Trump’s infrastructure program.

“At the end of the day if we get these things done we really believe we’re going to get our country back on the right track,” Ryan said of the GOP agenda.