The Republican proposal to overhaul the Affordable Care Act cleared a key hurdle Thursday, as the House Budget Committee narrowly voted to move it to the House floor and recommended a series of changes to the plan reflecting concerns from conservatives and centrists.

All of the panel’s Republicans and five Democrats supported a motion to change the system of tax credits created under the plan to ensure they are “afforded to the population that they are intended to serve,” an idea embraced across the ideological spectrum, including among centrists whose votes could be key.

The committee voted along party lines for a pair of motions supporting additional cuts to Medicaid beyond what’s in the bill — and for a third motion endorsing a requirement that “able-bodied” participants in the program work in exchange for their benefits. Conservatives have championed these ideas.

It remains unclear whether the Budget Committee’s nonbinding recommendations will make it into the final bill. Any substantive changes to the measure would be made by the House Rules Committee, which controls how the measure is presented and debated on the floor.

(Bastien Inzaurralde/The Washington Post)

Even as there were signs of progress and Speaker Paul D. Ryan (R-Wis.) sounded optimistic notes, the bill’s fate was still very much in doubt, as conservatives plotted new ways to compel GOP leaders to move the bill further to the right and registered their concerns in the Budget Committee proceedings. Meanwhile, Sen. Susan Collins (R-Maine), a moderate who has taken issue with the bill, told the Portland Press-Herald she would not vote for it without changes. “This is not a bill I could support in its current form,” she said.

The panel voted 19 to 17 to advance the bill, known as the American Health Care Act, before it started the hours-long process of debating various changes to propose. Three Republicans voted against it — Reps. Dave Brat (Va.), Gary Palmer (Ala.) and Mark Sanford (S.C.) — all of them members of the House Freedom Caucus, a group of hard-right lawmakers. All the Democrats voted against it.

Sanford said the bill remains “a work in progress” and did not rule out supporting the bill if major changes­ are made before it comes to the floor for a final House vote.

Rep. Mark Meadows (R-N.C.), the chairman of the Freedom Caucus, said the group is now drafting changes­ that they believe could garner widespread support and that could be introduced as soon as Friday. He declined to discuss what might be in the package but said he was in talks with multiple senators about it.

“We’re working very diligently to try to make sure that any amendment that we put forth has a real chance of success,” he said

The proposed change to the tax credits, which are in the bill to replace federal insurance subsidies in the ACA, was by far the most bipartisan sentiment of the day. The motion offered by Rep. Tom McClintock (R-Calif.) captured the concerns of members in both parties who have suggested focusing them more squarely on the working poor. The credits would be available to individuals making up to $115,000 a year under the present bill.

“The credits need to be enough for somebody to buy insurance,” said Rep. John Faso (R-N.Y.). “Whether it happens here in the House, or whether it happens as product of negotiation with the Senate, I think something is going to be addressed there.”

What’s next for the Obamacare replacement bill

A Congressional Budget Office report released Monday found that older and low-income people could face major premium hikes under the GOP plan, with the tax credits failing to fully substitute for the ACA subsidies. In one example put forward by the nonpartisan analysts, the yearly premiums for a 64-year-old making $26,500 a year is estimated to go from $1,700 to $14,600 under the Republican bill.

Still, most Democrats on the committee opposed the motion, arguing that it does not go far enough to reverse what’s already in the House bill.

“We don’t put lipstick on a pig, and I just can’t amend a bad bill,” said Rep. Barbara Lee (D-Calif.).

One of the proposed revisions that passed solely with Republican support, offered by Rep. Todd Rokita (R-Ind.), favored allowing the option for states to choose a Medicaid “block grant” in lieu of the capped reimbursement model embraced by the GOP bill. Under a block grant model, states would get a fixed payment they could use to provide health care largely as they please, although the payments would not necessarily grow with the population eligible for government aid.

Another, from Rep. Matt Gaetz (R-Fla.), expressed support for amendments to the bill “that do not incentivize new Medicaid enrollment.”

“It’s fiscally irresponsible, it’s inconsistent with free-market principles, and it should not be reflected in this legislation,” Gaetz said of the ACA’s Medicaid expansion. “The way to save Medicaid is not to explode it.”

Palmer, who offered the motion to add work requirements, said the ACA transformed Medicaid into “a permanent welfare benefit” that defied the original purpose of the program.

“When Medicaid was created, it wasn’t intended to become an entitlement for able-bodied adults,” he said. “Instead, it was meant to be a temporary safety net to protect the most vulnerable. It was meant for seniors and individuals with disabilities, pregnant women and children.”

Rep. Jan Schakowsky (D-Ill.) said that the change would be “not only punitive but counterproductive in the long run” and that Republicans’ “ultimate goal is simply to kick people off of Medicaid and not to help them find employment.”

Palmer’s proposal could find its way into the bill to ease its passage, since it has been under intense fire from the right in a chamber dominated by Republicans.

The committee action came a day after Ryan said that the bill must change to pass the House, marking a significant retreat from his earlier position that the legislation would go down if lawmakers made major alterations to it.

Addressing reporters Thursday morning, Ryan sought to emphasize that the House bill is one of several steps that the GOP plans to take to repeal and replace the ACA. He dismissed suggestions of discord between him and the White House over the bill, saying, “We are clearly in sync on this.”

“The president of the United States is the one who’s been mediating this,” Ryan said. “The president of the United States is the one who’s bringing people together, sitting around a table, hashing out our differences, so that we can get to a consensus document.”

President Trump has been meeting with conservative lawmakers and activists who say the president seems open to moving the bill in their direction, creating more confusion about what the final product will look like and whether it can pass the Senate, where there is growing bipartisan concern about it.

Opening Thursday’s Budget Committee meeting, Chairman Diane Black (R-Tenn.) called the House bill “the conservative health-care vision that we’ve been talking about for years,” and she urged Republican skeptics on the panel to have an open mind. She called the bill a “good first step.”

Democrats spoke vehemently against the plan. “This is Robin Hood in reverse, but far worse,” said Rep. John Yarmuth (Ky.), the top-ranking Democrat on the committee. He highlighted the CBO analysis this week that projected that 14 million fewer Americans would be insured after one year under the plan.

Democrats on the committee pushed a series of amendments to the bill that were rejected mostly along party lines. They sought to strike provisions that would increase costs for poor or middle-class households and require that the secretary of health and human services certify the proposal would not increase the number of uninsured Americans, among other things.

One Democratic recommendation attracted support from a Republican: Faso voted for a motion to remove from the bill a provision that would bar federal funding from Planned Parenthood for one year.

Kelsey Snell, Elise Viebeck and David Weigel contributed to this report.