WASHINGTON — House Republicans narrowly passed legislation Thursday to roll back the Affordable Care Act, delivering on a yearslong campaign promise despite mounting concerns from patient advocates and health care groups that the legislation would strip protections enjoyed by millions of Americans.

The tight vote, 217-213, with all Democrats opposed, underscored the limited appeal of the American Health Care Act, which passed thanks to last-minute deal-making and the personal intervention of President Donald Trump. Even so, 20 Republicans defected to vote against the measure.

After House GOP leaders had shelved previous attempts to advance the bill because of a lack of support, Thursday’s vote was a major legislative victory for Trump, likely providing momentum for his other priorities and bolstering his efforts to be seen as a leader who can govern with the Republican majority in Congress.

“Make no mistake, this is a repeal and replace of Obamacare,” Trump said at a Rose Garden reception for Republicans at the White House immediately after the vote. “It’s dead. It’s essentially dead.

“It’s going to be an unbelievable victory when we get it through the Senate,” he added.

But the future of the bill remains highly uncertain as it moves to the Senate amid deep reservations among Republicans there about the potential that Americans will lose their health care coverage under the measure.

The narrow passage, which was uncertain until the final votes were cast, ensured that health care once again will be a dominant issue in the mid-term elections.

Needing every vote they could get, Republican leaders pressed many of their members from swing districts to vote for the bill. Democrats are likely to use those votes against Republicans when they run for re-election, just as Republicans did ousting Democrats after Obamacare was passed in 2010.

Democrats sang, “Hey, hey, hey, goodbye,” on the House floor as the bill was being approved, taunting that voters would boot Republicans from office as a result.

Protesters chanted “Shame on you!” outside the Capitol as Republicans boarded buses to whisk them to the White House.

House Minority Leader Nancy Pelosi, D-Calif., orchestrated a full-scale floor opposition Thursday against what she called the “moral monstrosity of Trumpcare,” but in the end, Democrats were unable to block the measure.

Rep. Jim McGovern, D-Worcester, said he would continue fighting to prevent the bill from becoming law.

House Speaker Paul D. Ryan, R-Wis., told lawmakers this was their moment to make good on their promise to voters.

“Are we going to be men and women of our word? Are we going to keep the promises we made? Or are we going to falter?” Ryan said in an unusually fiery speech ahead of the vote. “Let us pass this bill to put Obamacare behind us.”

The full cost and impact of the final changes to the bill remain unclear because GOP leaders called the vote without first waiting for a new analysis from the nonpartisan Congressional Budget Office. A previous analysis, before amendments were made to appease both conservative and centrist factions of the party, estimated the GOP plan would leave 24 million more Americans without health care coverage by 2026.

The legislation cuts more than $1 trillion in federal health care assistance to low- and moderate-income Americans, primarily through a historic retrenchment in Medicaid, the half-century-old government health plan for the poor.

It stands to reverse an expansion of health care under Obamacare that has brought the nation’s uninsured rate to the lowest level recorded — an additional 20 million Americans have gained coverage.

The vote was swiftly condemned by a wide range of patient advocates, physicians and other health care groups.

“American lives are at stake,” warned Dr. Georges C. Benjamin, executive director of the American Public Health Assn., who urged Senate leaders not to be as “reckless, shortsighted and heartless” as the House.

Potentially faring best in the House bill would be wealthy Americans and the insurance industry, which would benefit from as much as $600 billion thanks to the bill’s elimination of taxes under Obamacare that have helped pay for the coverage expansion. Several studies have shown that Trump’s own supporters, living in conservative, rural areas, would fare the worst, paying higher premiums or losing benefits.

A key change from the original bill sought by the conservative House Freedom Caucus allows states to apply for waivers from some of Obamacare’s most popular requirements, including the ban on insurers charging more for patients with pre-existing medical conditions.

Advocates for patients with cancer, diabetes and other serious illnesses fear that would allow insurers to once again bill people with these diseases thousands of dollars more for coverage, effectively making coverage unaffordable.

Late Wednesday, another amendment was added to win back centrists worried about the impact of those state waivers. The late fix will pour an additional $8 billion into high-risk insurance pools to cover patients with pre-existing conditions who can’t obtain traditional coverage.

The additional money did little to convince those who work in health care, who have cautioned that these pools, which were common before Obamacare, have proved woefully inadequate to cover the medical needs of sick patients shut out of commercial health insurance.

Dr. Andrew W. Gurman, president of the American Medical Assn., said the latest proposed changes “tinker at the edges without remedying the fundamental failing of the bill _ that millions of Americans will lose their health insurance as a direct result of this proposal.”

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The changes also did not allay the concerns of many Senate Republicans, who have openly criticized the legislation and the rushed process that House leaders used to advance it.

Sen. Rob Portman, R-Ohio, whose state has expanded Medicaid coverage through Obamacare, cautioned that any changes to the current law “must be made in a way that does not leave people behind.”

“I continue to have concerns that this bill does not do enough to protect Ohio’s Medicaid expansion population, especially those who are receiving treatment for heroin and prescription drug abuse,” Portman said.

Sen. Lindsey Graham, R-S.C., a fierce critic of Obamacare, said in a tweet that the House replacement “should be viewed with caution,” noting that it had been passed without an analysis from the budget office and with only three hours of debate.

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The vote turned out to be far more difficult than initially thought, particularly since the GOP-led House had voted more than 50 times over the years to repeal Obamacare. But those votes were largely symbolic because lawmakers knew President Barack Obama would veto any bill that reached his desk.

With the prospects that their legislation might actually become law and as public opinion polls showed Obamacare’s popularity rising, lawmakers weighed the decision much more carefully.

Many Republican lawmakers appeared to be resigned to punting the bill to the Senate, where they acknowledge it will be changed again or stall.

“It’s not that I’m happy with this bill. I am not,” said Rep. Mario Diaz-Balart, R-Fla., who voted for the bill. “But there’s a long way to go.”

Ahead of the vote, Republicans huddled in the Capitol basement, using the theme song from the movie “Rocky” and “Taking Care of Business” as a soundtrack.

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