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115th Congress on the American Health Care Act of 2017 (May, revised AHCA bill)

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115th Congress, 2017-2018
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115th Congress, 2017-2018
Healthcare policy
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For more on healthcare policy, view the following articles:
•Healthcare overview
•Graham-Cassidy Obamacare replacement plan
•Republican effort to repeal the ACA, July 2017
•Better Care Reconciliation Act of 2017 (Senate bill)
•115th Congress on the Better Care Reconciliation Act of 2017
•Republican senators on the BCRA
•American Health Care Act of 2017 (House bill)
•House's second attempt to pass the AHCA, April - May
•House's initial attempt to pass the AHCA, March
•House roll call vote on the AHCA
•Republicans who were likely to vote against the AHCA, March
•Timeline of ACA repeal and replace efforts
•Federal policy on healthcare, 2017-2020

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See also: 115th Congress on the American Health Care Act of 2017 (March)

On May 4, 2017, the U.S. House of Representatives passed the American Health Care Act of 2017 (AHCA), a reconciliation bill that proposed modifying the budgetary and fiscal provisions of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare, by a vote of 217-213. Two hundred and seventeen Republicans voted to approve the bill. Twenty Republicans and 193 Democrats voted against the bill.[1]

Senate Republicans released their version of the AHCA—the Better Care Reconciliation Act of 2017 (BCRA)—on June 22, 2017. On July 17, 2017, after weeks of negotiating the bill, Senate Majority Leader Mitch McConnell (R-Ky.) said that his party was unable to agree on a replacement bill for the ACA. During the last week of July, the Senate voted on three major proposals to repeal and replace the ACA. A procedural vote on the BCRA was rejected by a vote of 43-57. A proposal to repeal the ACA and delay the effective date for two years to provide time for a replacement bill failed by a vote of 45-55. The final major amendment—the "skinny bill"—was rejected by a 49-51 vote. It contained the provisions to repeal the requirements for individuals to enroll in health insurance and for employers to offer it, among other provisions.[2][3][4][5][6]

After the skinny bill failed, McConnell said, “it is time to move on,” and he called the final defeat disappointing.[7]

Senate consideration of AHCA

See also: 115th Congress on the Better Care Reconciliation Act of 2017

What did Senate Republicans think of the bill?

Senate Republicans said that the House version of the AHCA would undergo changes before it could be brought to the floor for a vote. Sen. Roy Blunt (R-Mo.) said that the upper chamber would spend time changing the bill and not rush it through to a vote. He said, “I can’t imagine there will be a rush to take up the bill as much as a real concentrated effort to find where the 51 votes might be if the 51 votes are still available.”[8]

Some Senate Republicans expressed opposition to the bill because of the changes it would make to Medicaid and the likelihood that it would raise healthcare costs for low-income families and individuals age 50 to 65. Additionally, some Republicans expressed opposition to the bill because they said that it would not lower premiums or deductibles.

What did Senate Democrats think of the bill?

All Senate Democrats expressed opposition to the AHCA. Senate Minority Leader Chuck Schumer (D-N.Y.) said, “This bill is going nowhere fast in the United States Senate. Senate Republicans should refuse to follow their House colleagues over a cliff, reject repeal, and work with Democrats to improve our healthcare system in a bipartisan way.”[9]

Senate Democrats said that they did not support repealing and replacing the ACA. Instead, they said that they supported fixing President Barack Obama's signature healthcare law.

Could the AHCA have been filibustered?

No. The AHCA went through the budget reconciliation process, which allows legislation to pass with a simple majority instead of the usual 60-vote threshold to end a filibuster in the Senate. The Congressional Budget Act allows reconciliation to be used for legislation that changes outlays (spending), revenues, and the federal debt limit. The Obama administration used this process to help it pass parts of the ACA in 2010.[10][11]

What is the Byrd Rule and how could it have impacted the AHCA?

The Byrd rule requires reconciliation bills to relate solely to budgetary matters. Under the rule, the Senate parliamentarian had to decide whether the provisions included in the AHCA were sufficiently budget-related. One concern was the provision that would have allowed insurers to increase monthly premiums by 30 percent for one year for individuals who decided to not maintain continuous health insurance coverage. According to Business Insider, “Since the money from the penalty goes to the insurance companies, the rule does not affect tax receipts for the federal government akin to the ACA's current individual mandate, in which the penalty is paid to the IRS.” This provision and others could have caused problems for the GOP. Rep. Trent Franks (R-Ariz.) commented on the process, saying, "The House has the untenable task of trying to craft a bill that will fit through the matrix of the Byrd Rule. It's essentially like trying to force a giraffe through a keyhole. If you get the job done, he looks a little differently on the other side."[12]

Senate Parliamentarian flags Hyde Amendment language in AHCA

Senate Parliamentarian Elizabeth MacDonough said that Hyde Amendment language in the AHCA, as it was written at the time she examined it, would not be allowed under the Byrd Rule. The AHCA would have prevented individuals from using refundable tax credits for private insurance plans that covered abortion. According to The Hill, “Arguably, attaching Hyde language to the refundable tax credits is designed more to shape abortion policy than affect how much money is spent to subsidize healthcare coverage.” If senators were unable to find a workaround to prevent federal funding from being used to pay for abortions—excluding cases of rape and incest and when a mother’s life was in danger—it could have prevented conservative senators from supporting the bill.[13]

Sen. James Inhofe (R-Okla.) commented on what would happen to the AHCA if Hyde Amendment language was removed. He said, “Would that be a deal killer? I’d have to think about it. I’m inclined to think it would [be].”[13]

Senate Finance Committee Chairman Orrin Hatch (R-Utah) agreed, saying, “I think a lot of people do think that’s essential.”[13]

How was the AHCA passed in the House?

After a failed attempt at replacing elements of the ACA, House Republicans developed a revised version of the AHCA. Members of the House Freedom Caucus, who initially opposed the bill, announced their support for the AHCA on April 26, 2017, after an amendment that would have allowed states to opt out of some provisions of the ACA was introduced.[14]

The House Freedom Caucus said in a statement, "While the revised version still does not fully repeal Obamacare, we are prepared to support it to keep our promise to the American people to lower healthcare costs. We look forward to working with our Senate colleagues to improve the bill. Our work will continue until we fully repeal Obamacare."[14]

Although the amendment earned the support of the House Freedom Caucus, Co-Chairman of the Tuesday Group Charlie Dent (R-Pa.) expressed doubt that centrist Republicans would change their votes. Dent said, “My sense is the members of our group who were opposed to the bill before remain opposed, nothing's changed. That's my sense. You have to ask each one of them individually.”[15]

In an attempt to earn support for the AHCA from centrist Republicans, Rep. Fred Upton (R-Mich.) began working on an amendment to address the concerns of those who opposed the AHCA because it likely would have hurt individuals with pre-existing conditions. Upton’s amendment proposed providing states with an additional $8 billion over five years to fund high-risk pools for individuals with pre-existing conditions.[16]

House Minority Leader Nancy Pelosi (D-Calif.) criticized the amendment, saying, “What you would need is probably about $200 billion over 10 years. What they’ve done is $8 billion over five years. If you divide that by the number of people who have a pre-existing medical condition, you get about [$200 or $300] a year. It’s a joke. It’s a very sad, deadly joke.”[17]

After meeting with President Donald Trump on May 3, 2017, Upton was optimistic that his amendment would get the GOP the 216 votes they needed. He said, "I think it is likely now to pass the House.”[18]

What was the MacArthur-Meadows amendment?

The amendment created by Tuesday Group Co-Chair Tom MacArthur (R-N.J.) and House Freedom Caucus Chairman Mark Meadows (R-N.C.), proposed retaining the 10 essential health benefits as the federal standard for what health plans had to cover, but it also proposed allowing states to acquire a waiver from the requirement. The amendment also proposed retaining the following provisions in the ACA:[19]

  • the prohibition on denying coverage for pre-existing conditions;
  • the requirement to cover individuals on their parents' health plan until age 26; and
  • limits on how much insurers may vary premiums for reasons such as age, gender, and health status (known as community rating).

Additionally, the amendment proposed allowing states to obtain waivers from the community rating provisions, except for the rules limiting premium variance based on gender and age. States could have only waived the limits on varying premiums based on health status if they had also established a publicly funded high-risk pool to cover individuals with costly conditions.[19]

House vote on AHCA

On May 4, 2017, the House passed HR 1628—the American Health Care Act of 2017—by a vote of 217-213. Two hundred and seventeen Republicans voted to approve the bill. Twenty Republicans and 193 Democrats voted against the bill. The full roll call vote can be viewed here.


American Health Care Act of 2017 (HR 1628)

Yes check.svg Bill passed (217-213) on May 4, 2017
Proposed modifying the budgetary and fiscal provisions of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare.[20]

Who were the 20 Republicans who voted against the AHCA?

The following Republicans voted against the AHCA:

Background on AHCA

See also: 115th Congress on the American Health Care Act of 2017 (March)

On March 6, 2017, House Republicans introduced the American Health Care Act of 2017 (AHCA). The bill proposed repealing the penalties on individuals for not maintaining health coverage and on employers for not offering coverage. The ACA's subsidies for purchasing insurance would have ended, as would have enhanced federal funding for states that expanded Medicaid. The bill also proposed a system of tax credits, based on age rather than income, and a penalty in the form of increased premiums for individuals who chose not to maintain continuous coverage.[21]

The United States House of Representatives was expected to vote on the AHCA on Thursday, March 23, 2017, but the vote was canceled. It was rescheduled for Friday, March 24, but House Republican leaders withdrew the bill amid dwindling support. Two amendments added to the bill—one that would have allowed work requirements and block grants in Medicaid, and another that would have repealed the ACA’s essential benefits provision—did little to garner support among Republicans in opposition.[22][23][24]

For more on the March 2017 attempt to vote on the AHCA, click here.

What is the ACA or Obamacare? The Patient Protection and Affordable Care Act, commonly known as the Affordable Care Act (ACA) or Obamacare, was signed into law by President Barack Obama (D) on March 23, 2010. The aim of the law was to provide health insurance coverage to more Americans, primarily through individual health insurance marketplaces and an expansion of the Medicaid program. Click here to read more about the healthcare law.[25][26]

Timeline of ACA repeal and replace efforts

  • July 28, 2017: The Senate voted on an amendment from Senate Majority Leader Mitch McConnell (R-Ky.), also referred to as the "skinny bill." The amendment contained the provisions to repeal the requirements for individuals to enroll in health insurance and for employers to offer it, among other provisions. The amendment was rejected by a 49-51 vote. Sens. Susan Collins (R-Maine), John McCain (R-Ariz.), Lisa Murkowski (R-Alaska) joined 48 Democrats in voting against the amendment.[27][28]
  • July 25, 2017: The Senate held a vote on a motion to proceed to the American Health Care Act of 2017 (AHCA), the House-passed repeal and replace bill. The motion was approved 51-50. Republican Sens. Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) and all Senate Democrats voted against the motion. Vice President Mike Pence voted in favor of the bill to break the 50-50 tie. Sen. John McCain (R-Ariz.), who was diagnosed with brain cancer the previous week, returned to Capitol Hill to cast a vote in favor of the motion. Without his vote, the motion would have failed.[29]
  • July 21, 2017: The Senate parliamentarian ruled that the provision suspending funding for Planned Parenthood for one year in the revised BCRA did not meet the rules of reconciliation. She also ruled that the provision prohibiting the use of tax credits for plans that cover abortions in circumstances other than rape or incest or to save the life of the mother did not meet the requirements.[30]
  • July 20, 2017: The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) released a report estimating the cost of the revised version of the Better Care Reconciliation Act (BCRA). Key findings can be viewed here.[31]
  • July 19, 2017: After meeting with Trump in the White House, Senate leadership attempted to revive the BCRA or a version of it.[32]
  • July 17, 2017: Senate Majority Leader Mitch McConnell (R-Ky.) said that his party was unable to agree on a final version of the BCRA and would instead vote on a bill to repeal, but not replace, the ACA.[33][34]
  • July 15, 2017: Senate Majority Leader Mitch McConnell (R-Ky.) said that the Senate would not vote on the BCRA until after Senator John McCain (R-Ariz.) recovered from his eye surgery. McCain was recovering at his home in Arizona.[35]
  • July 11, 2017: Following a briefing with GOP senators, Senate Majority Leader Mitch McConnell (R-Ky.) delayed the start of the Senate's August recess to the third week in August in order to complete work on the BCRA and other items on the legislative agenda.[36]
  • June 27, 2017: Senate Republican leaders postponed a vote on the BCRA until after the July 4 recess.[37]
  • June 26, 2017: The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) released a report estimating the cost of the Better Care Reconciliation Act (BCRA) and its impact on the number of uninsured. Key findings can be viewed here.[38]
  • June 6, 2017: The Senate Budget Committee announced that the AHCA complied with the Senate reconciliation process. House Republicans were waiting for the committee's verdict on the AHCA before sending it to the upper chamber.[39]
  • May 24, 2017: The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) released a report estimating the cost of the AHCA as amended and its impact on the number of uninsured. The AHCA would reduce the federal deficit by $119 billion between 2017 and 2026 due to a $1.1 trillion decrease in direct spending and a $992 billion reduction in revenues. Compared to the ACA, 14 million more people would be uninsured in 2018 under the AHCA, and 23 million more people would be uninsured in 2026. In total, under the AHCA, 51 million people would be uninsured in 2026, compared to 28 million who would be uninsured under the ACA.[40]
  • May 4, 2017: The House passed the AHCA by a vote of 217-213.[1]
  • May 3, 2017: House Majority Leader Kevin McCarthy (R-Calif.) said that the House would hold a vote on the revised version of the AHCA on May 4, 2017. He wrote in a tweet, "Doing nothing is not an option. The American people are tied to #Obamacare’s sinking ship, and we have to act now. #AHCA."[41]
  • May 2, 2017: The House voted to approve waiving a rule requiring lawmakers to wait at least one day before voting on the AHCA. It would allow leaders in the House GOP to hold a vote on the AHCA as soon as they secured enough votes for passage.[42]
  • April 27, 2017: House Majority Leader Kevin McCarthy (R-Calif.) said that the House would not vote on the revised version of the AHCA before President Donald Trump 100th day in office.[43]
  • April 26, 2017: The House Freedom Caucus said that they would support the AHCA because of an amendment that would allow states to opt out of some provisions of the ACA.[14]
  • April 13, 2017: House Republicans added an amendment to the AHCA in an attempt to unite the party behind the bill. Rep. Tom MacArthur (R-N.J.), co-chair of the Tuesday Group, and Rep. Mark Meadows (R-N.C.), head of the House Freedom Caucus, introduced an amendment that proposed retaining the 10 essential health benefits as the federal standard for what health plans must cover, but would allow states to acquire a waiver from the requirement. Other provisions in the ACA that would be retained by the amendment included the prohibition on denying coverage for pre-existing conditions, the requirement to cover individuals on their parents' health plan until age 26, and limits on how much insurers may vary premiums for reasons such as age, gender, and health status (known as community rating). In addition to waiving the essential benefits standard, the amendment would allow states to obtain waivers from the community rating provisions, except for the rules limiting premium variance based on gender and age. States could only waive the limits on varying premiums based on health status if they had also established a publicly funded high-risk pool to cover individuals with costly conditions.[19][44][45]
  • April 3, 2017: White House officials discussed changes to the AHCA with the House Freedom Caucus. Officials proposed allowing "states to choose to apply for waivers to repeal two ObamaCare regulations that conservatives argue are driving up premiums. Those two regulations detail ObamaCare's essential health benefits, which mandate which health services insurers must cover, and 'community rating,' which prevents insurers from charging sick people higher premiums," according to The Hill.[46]
  • Rep. Mark Meadows (R-N.C.) said that the proposed changes would result in enough votes from Freedom Caucus members to pass the bill, but he said that he wanted to see the full text of the legislation before making a final decision.[46]
  • March 24, 2017: The House was expected to vote on the AHCA, but House Republican leaders withdrew the AHCA from consideration amid dwindling support.[23]
  • March 24, 2017: The House Rules Committee approved an amendment to the AHCA that would have repealed the ACA's requirement that insurers provide federally determined essential health benefits. Under the amendment, each state instead would have been required to determine which essential benefits insurers licensed in that state must cover. The amendment also would have provided $15 billion to states to promote access to preventive care, dental care, and vision care, and to provide maternity and newborn care and mental health services. The $15 billion would have been funded by maintaining a 0.09 percent Medicare tax on high-income earners for six years.[47][48][49]
  • March 23, 2017: The House was expected to vote on the AHCA, but the vote was canceled.[23]
  • March 20, 2017: The House added an amendment to the AHCA that provided for extra funding for tax credits for older Americans to help them pay their premiums and instructed the Senate to design the tax credits. It removed a provision in the original bill that would have allowed individuals to deposit leftover tax credit money into a health savings account. The amendment would have allowed states to establish work requirements for their Medicaid programs and would have allowed states to receive federal Medicaid funding in the form of a per-member amount or block grants, whichever they chose. The amendment would have repealed many of the ACA's taxes and fees and would have delayed the 40 percent excise tax on employer-sponsored plans until 2026. Finally, the amendment contained a provision specific to New York state: it would have prohibited New York from receiving federal reimbursement for Medicaid payments that counties make to the state in an attempt to shift more Medicaid spending to the state level.[50]
  • March 6, 2017: Representatives Kevin Brady (R-Texas) and Greg Walden (R-Ore.) introduced the American Health Care Act of 2017, a reconciliation bill to modify the budgetary and fiscal provisions of the ACA. It did not propose completely repealing the ACA.[21]
  • January 23, 2017: Sens. Bill Cassidy (R-La.) and Susan Collins (R-Maine) introduced S 191—the Patient Freedom Act of 2017. The legislation proposed replacing the ACA.[54][55]
  • Cassidy discussed the bill, saying, "I would say what we’re doing is moving the locus of repeal to state governments. On the one hand, that is philosophically consistent with where Republicans are. States should have the right to choose. It is also consistent with our long-stated [principle], ‘If you like your insurance, you can keep it.’"[56]
  • January 12, 2017: The Senate passed S Con Res 3, a budget resolution to begin rolling back the ACA, by a vote of 51-48. Sen. Rand Paul (R-Ky.) was the only Republican who voted against the budget resolution because he said that it increased the federal debt. Paul added, “I won’t vote for a terrible budget just to repeal Obamacare. … If I have to weigh the two problems, I actually think the debt is a more important problem than Obamacare.”[58][59]
  • January 4, 2017: The Senate passed S Con Res 3, a motion to begin debating a budget bill, by a vote of 51-48. The budget resolution proposed repealing parts of the ACA that related to the budget and taxes. The final legislation was expected to eliminate provisions that provided tax credits for low-income individuals to obtain health coverage, required all individuals to obtain coverage, and required employers to provide coverage to their employees.[60][61]

What was the AHCA?

On March 6, 2017, Representatives Kevin Brady (R-Texas) and Greg Walden (R-Ore.) introduced the American Health Care Act. The reconciliation bill, which would only impact the budgetary and fiscal provisions of the ACA, does not contain a provision to repeal the law in its entirety. It was similar to a draft version of the bill obtained and released by Politico on February 24, 2017.[21]


Individual and benefit mandates
The American Health Care Act would repeal the tax penalties on individuals for not maintaining health coverage and on employers for not offering coverage. Instead, the bill would require insurers to increase monthly premiums by 30 percent for one year for individuals who did not maintain continuous health insurance coverage. The bill would not repeal the ACA's requirement that insurers cover the ten essential benefits outlined by the federal government. However, an amendment added on April 13 would allow states to acquire a waiver from the requirement. This amendment was a change from an amendment added on March 24, which would have repealed the federal essential benefits requirement entirely and required states to determine their own benefits standards.[21]

The bill also would maintain bans on lifetime and annual benefit limits and insurance plans would still be required to cover preventive care at no cost to the patient.[21]

Tax credits and health exchanges
Starting in 2020, the bill would eliminate the ACA's income-based tax credits and subsidies. The bill instead would provide different tax credits based on age. Individuals under 30 would receive a $2,000 annual credit, which would increase by age group up to $4,000 for individuals over the age of 60. The tax credits would be available for anyone not eligible for an employer-sponsored plan or government health program, such as Medicaid.[21]

In the meantime, the ACA's advanced premium tax credits would be increased for young individuals earning incomes above 150 percent of the federal poverty level, and decreased for older individuals earning that amount. Cost-sharing subsidies, which reduce enrollees' share of costs under a plan, would be repealed in 2020.[21]

The health insurance exchanges would remain in operation, as well as the open enrollment and special enrollment periods. However, tax credits could be used for plans sold on or off the exchanges; under the ACA, tax credits could only be used for on-exchange plans.[21]

Insurance market rules and public programs
Insurers would still be prohibited from denying coverage for pre-existing conditions. The bill also would provide $100 billion to states to establish various methods of covering particularly high-risk individuals with such conditions. Insurers also would still be required to allow dependents to remain on their parents' insurance coverage until age 26. However, insurers would be allowed to charge premiums for older individuals as much as five times higher than for younger individuals; under the ACA, premiums for older individuals could only be three times greater.[21]

An amendment added to the bill on March 24 would also provide $15 billion to states to promote access to preventive care, dental care, and vision care, and to provide maternity and newborn care and mental health services. An amendment added to the bill on April 6 would allocate another $15 billion for a reinsurance program, which reimburses insurers for covering high-cost individuals. An amendment added to the bill on April 13 would allow states to acquire a waiver to allow insurers to vary premiums based on health status (like preexisting conditions), as long as the state had established a high-risk pool for individuals with preexisting or costly conditions. In addition, individuals with preexisting conditions would only be subject to higher premiums if they had not maintained continuous health insurance coverage. An amendment added to the bill on May 3 would provide an additional $8 billion over five years to fund high-risk pools for individuals with preexisting conditions.[62][63]

Medicaid
The bill would make statutorily voluntary the ACA's Medicaid expansion, which allowed states to widen eligibility for the program to individuals earning incomes up to 138 percent of the federal poverty level. However, beginning in 2020, no new states could expand their Medicaid programs. Also beginning in 2020, the bill would no longer provide enhanced federal reimbursements for any state spending on individuals that enroll under expanded Medicaid after December 31, 2019.[21]

The original bill also would convert Medicaid financing from an open-ended entitlement to a per-member amount. This amount would be adjusted based on five distinct groups: elderly, blind and disabled, children, expansion adults, and other adults. It also would provide $10 billion over five years in safety net funding for states that did not expand Medicaid. The law would set a target spending amount for states based on fiscal year 2016 expenditures that would increase annually. Beginning in 2020, states that spent more than the targeted amount on their Medicaid programs in any given year would receive a reduced amount of funding the following year.[21]

Under the bill, state Medicaid programs would no longer have to cover the 10 essential health benefits that private plans must cover under the ACA.[21]

Planned Parenthood
The bill would suspend federal funding available to states to make payments to community health centers that provide family planning, reproductive health, and related medical services and also provide abortions. This would include the nonprofit organization Planned Parenthood. The funding would be suspended for one year.[21]

Amendments

The following is a list of approved amendments to the American Health Care Act.

May 3 amendment
On May 3, 2017, Representative Fred Upton (R-Mich.) offered an amendment to the AHCA in an attempt to secure the votes of moderate Republicans. The amendment would provide states with an additional $8 billion over five years to fund high-risk pools for individuals with preexisting conditions. After meeting with President Donald Trump on May 3, 2017, Upton was optimistic that his amendment would get the GOP the 216 votes they need to pass the bill. He said, "I think it is likely now to pass the House."[62][64]

April 13 amendment
On April 13, 2017, House Republicans added an amendment to the AHCA in an attempt to unite the party behind the bill. The amendment was the culmination of negotiations between Tom MacArthur (R-N.J.), co-chair of the Tuesday Group, the moderate wing of the Republican Party, and Mark Meadows (R-N.C.), head of the House Freedom Caucus, the conservative and libertarian-leaning wing of the party.[65]

The amendment would retain the 10 essential health benefits as the federal standard for what health plans must cover, but would allow states to acquire a waiver from the requirement. The 10 essential benefits health plans were required to cover under the Affordable Care Act included the following:[19][66]

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

This portion of the amendment was a change from the amendment added on March 24, which would have repealed the federal essential benefits requirement entirely and required states to determine their own benefits standards.

Other provisions in the ACA that would be retained by the amendment included the prohibition on denying coverage for pre-existing conditions, the requirement to cover individuals on their parents' health plan until age 26, and limits on how much insurers may vary premiums for reasons such as age, gender, and health status (known as community rating).[19]

In addition to waiving the essential benefits standard, the amendment would allow states to obtain waivers from the community rating provisions, except for the rules limiting premium variance based on gender and age. States could only waive the limits on varying premiums based on health status (like preexisting conditions) if they had also established a publicly funded high-risk pool to cover individuals with costly conditions. In addition, individuals with preexisting conditions would only be subject to potentially higher premiums if they had not maintained continuous health insurance coverage.[19][67]

March 24 amendment
On March 24, 2017, the House Rules Committee approved an amendment to the AHCA that would repeal the ACA's requirement that insurers provide federally determined essential health benefits. Under the amendment, each state instead would be required to determine which essential benefits insurers licensed in that state must cover.[68][69][49]

The amendment also would provide $15 billion to states to promote access to preventive care, dental care, and vision care, and to provide maternity and newborn care and mental health services. The $15 billion would be funded by maintaining a 0.09 percent Medicare tax on high-income earners for six years.[49]

March 20 amendment
On March 20, 2017, the House offered an amendment to the AHCA providing extra funding for tax credits for older Americans to help them pay their premiums and instructing the Senate to design the bill's system of tax credits. It would remove a provision in the original bill that would have allowed individuals to deposit leftover tax credit money into a health savings account. The amendment would allow states to establish work requirements for their Medicaid programs and would allow states to receive federal Medicaid funding in the form of a per-member amount or block grants, whichever they chose. The amendment would repeal many of the ACA's taxes and fees and would delay the 40 percent excise tax on employer-sponsored plans until 2026. Finally, the amendment contained a provision specific to New York state: it would prohibit New York from receiving federal reimbursement for Medicaid payments that counties make to the state in an attempt to shift more Medicaid spending to the state level.[70]

Political background on the ACA

In 2010, the ACA passed Congress with only Democrats voting in favor of the bill. Although Democratic lawmakers expressed a desire to fix parts of the law, they strongly opposed any effort to repeal the ACA. Republicans attempted to repeal or change the ACA on multiple occasions but were unsuccessful. After Republicans took control of Congress and the White House in 2017, Republican lawmakers said that one of their main goals was to change President Barack Obama's signature healthcare law.[71][72]

Supporters of the law, such as House Minority Leader Nancy Pelosi (D-Calif.), have argued that healthcare is a right that the ACA helped guarantee. Pelosi, who was integral in getting the ACA passed, said, “[T]he Affordable Care Act was designed to protect Americans from rate increases by ensuring that tax credits go up as premiums rise, and by empowering consumers to shop around for the best plan in competitive marketplaces. Because of this landmark law, the uninsured rate has fallen to historic lows and health care costs are growing at the slowest rate in 50 years. Children, women, workers and families across the country have newfound health and economic security thanks to the ACA. With the Affordable Care Act, we have made monumental progress toward ensuring that health care is a right, not a privilege, for all Americans. The Affordable Care Act is working, and it will continue to work in spite of Republicans’ ceaseless attempts to strip health care from millions of hard-working families.”[73]

Critics of the ACA, such as Senate Majority Leader Mitch McConnell (R-Ky.), have said that the law is fundamentally flawed and that the exchanges were poorly designed. They have said that the regulations embedded in the law made health insurance expensive and unattractive to young, healthy people and that provisions intended to keep premiums affordable and maintain an optimal mix of healthy and sick enrollees have not worked. Critics have also said that the law has worsened the quality of care by disrupting the doctor-patient relationship.[74]

Previous attempt to repeal the ACA through reconciliation

The Restoring Americans' Healthcare Freedom Reconciliation Act of 2015 was a budget reconciliation bill that would have repealed several parts of the Affordable Care Act, commonly known as Obamacare, that impacted the federal budget, such as the advanced premium tax credits and the Medicaid expansion. It also would have suspended federal funding for Planned Parenthood for one year.

The bill was passed by Congress on January 6, 2016, but was vetoed by President Barack Obama (D) on January 8, 2016. If the measure had been enacted, many of the changes would have gone into effect in 2018, and Republicans said they would have used the two years in between to implement a replacement of the law.[75]

Continue reading about the Restoring Americans' Healthcare Freedom Reconciliation Act of 2015 here.

See also

Footnotes

  1. ↑ 1.0 1.1 Clerk.House.gov, "Final Vote Results For Roll Call 256," May 4, 2017
  2. ↑ The Hill, "Senate GOP revives negotiation over ObamaCare repeal and replace," July 19, 2017
  3. ↑ 3.0 3.1 Senate.gov, "On the Motion (Motion to Waive All Applicable Budgetary Discipline Re: Amdt. No. 270)," July 25, 2017
  4. ↑ 4.0 4.1 Senate.gov, "On the Amendment (Paul Amdt. No. 271 )," July 26, 2017
  5. ↑ Senate.gov, "On the Amendment (McConnell Amdt. No. 667 )," July 28, 2017
  6. ↑ Axios, "Here’s the Senate’s “skinny” health care bill," July 27, 2017
  7. ↑ The Hill, "McConnell: 'Time to move on' after healthcare defeat," July 28, 2017
  8. ↑ The Hill, "No. 2 Senate Republican: 'No timeline' on ObamaCare replacement bill," May 4, 2017
  9. ↑ ABC News, "How everyone is reacting to the House passing the GOP health care bill," May 4, 2017
  10. ↑ Congress.gov, "H.R.4872 - Health Care and Education Reconciliation Act of 2010," accessed May 8, 2017
  11. ↑ Healthcare.gov, "Read the Affordable Care Act," accessed May 8, 2017
  12. ↑ AOL.com, "'Trying to force a giraffe through a keyhole': An obscure Senate rule could kill the GOP's Obamacare replacement," March 10, 2017
  13. ↑ 13.0 13.1 13.2 The Hill, "Parliamentarian threatens deadly blow to GOP healthcare bill," June 8, 2017
  14. ↑ 14.0 14.1 14.2 The Hill, "Freedom Caucus endorses revised ObamaCare repeal-and-replace bill," April 26, 2017
  15. ↑ The Hill, "GOP takes step forward on ObamaCare replacement, but centrists elusive," April 26, 2017
  16. ↑ The Hill, "New hope for ObamaCare repeal? Key GOP lawmaker working on amendment," May 3, 2017
  17. ↑ The Hill, "Pelosi: New ObamaCare repeal bill is a ‘a very sad, deadly joke,'" April 3, 2017
  18. ↑ The Hill, "Key GOP reps will back ObamaCare repeal bill with new amendment," May 3, 2017
  19. ↑ 19.0 19.1 19.2 19.3 19.4 19.5 NPR, "MacArthur Amendment to the American Health Care Act," April 13, 2017
  20. ↑ Clerk.House.gov, "Final Vote Results For Roll Call 256," May 4, 2017
  21. ↑ 21.00 21.01 21.02 21.03 21.04 21.05 21.06 21.07 21.08 21.09 21.10 21.11 21.12 House Energy and Commerce Committee, "Budget Reconciliation Legislative Recommendations Relating to Repeal and Replace of the Patient Protection and Affordable Care Act," accessed March 7, 2017
  22. ↑ Politico, "Thursday vote on health care bill canceled," accessed March 23, 2017
  23. ↑ 23.0 23.1 23.2 The Hill, "House cancels ObamaCare repeal vote as GOP defections mount," accessed March 24, 2017
  24. ↑ PBS.org, "WATCH: Paul Ryan speaks after Republicans withdraw health care bill," accessed March 24, 2017
  25. ↑ Kaiser Family Foundation, "Summary of the Affordable Care Act," April 25, 2013
  26. ↑ Encyclopaedia Britannica, "Patient Protection and Affordable Care Act (PPACA)," June 26, 2015
  27. ↑ Senate.gov, "On the Amendment (McConnell Amdt. No. 667 )," July 28, 2017
  28. ↑ Axios, "Here’s the Senate’s “skinny” health care bill," July 27, 2017
  29. ↑ Senate.gov, "On the Motion to Proceed (Motion to Proceed to H.R. 1628)," July 25, 2017
  30. ↑ CNN, "Senate parliamentarian: Anti-abortion provisions in GOP health care bill violate budget rules," July 21, 2017
  31. ↑ Congressional Budget Office, "H.R. 1628, the Better Care Reconciliation Act of 2017: An Amendment in the Nature of a Substitute," July 20, 2017
  32. ↑ Politico, "Key Senate Republicans to meet and try to revive health bill," July 19, 2017
  33. ↑ CNBC.com, "McConnell says GOP doesn't have votes to replace Obamacare, but will vote on repeal in 'very near future,'" July 18, 2017
  34. ↑ CNBC, "GOP's Obamacare repeal-only push quickly collapses," July 18, 2017
  35. ↑ The Washington Post, "McConnell defers vote on Senate health-care bill as McCain recovers from surgery," July 16, 2017
  36. ↑ CNN, "McConnell delays start of recess until third week in August," July 11, 2017
  37. ↑ The Wall Street Journal, "Short on Backers, GOP Delays Vote on Health Bill," June 27, 2017
  38. ↑ Congressional Budget Office, "Congressional Budget Office Cost Estimate: Better Care Reconciliation Act of 2017," June 26, 2017
  39. ↑ The Hill, "Budget Committee: House healthcare bill can move to Senate," June 6, 2017
  40. ↑ Congressional Budget Office, "Congressional Budget Office Cost Estimate: American Health Care Act of 2017," May 24, 2017
  41. ↑ Twitter, "Kevin McCarthy," May 3, 2017
  42. ↑ The Hill, "House GOP paves way for fast-tracking potential healthcare vote," May 2, 2017
  43. ↑ The Hill, "Republicans won't vote on ObamaCare replacement bill this week," April 27, 2017
  44. ↑ National Association of Insurance Commissioners, "Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges," April 20, 2010
  45. ↑ Politico, "White House plans Obamacare showdown next week," April 20, 2017
  46. ↑ 46.0 46.1 The Hill, "Pence presents new healthcare offer to Freedom Caucus," accessed April 4, 2017
  47. ↑ The Hill, "Live coverage: Trump, GOP scramble for ObamaCare votes," March 24, 2017
  48. ↑ Washington Post, "This is why Obamacare is canceling some people's insurance plans," October 29, 2013
  49. ↑ 49.0 49.1 49.2 U.S. House of Representatives, "Policy Amendment to the Manager's Amendment (Policy Changes) to H.R. 1628," accessed March 24, 2017
  50. ↑ Politico, "GOP leaders pile on sweeteners to sell Obamacare repeal," March 20, 2017
  51. ↑ The Hill, "Budget panel advances ObamaCare bill with three GOP defections," accessed March 16, 2017
  52. ↑ EnergyCommerce.House.gov, "Energy and Commerce Committee Advances Legislation to Repeal and Replace Obamacare," accessed March 9, 2017
  53. ↑ WaysandMeans.gov, "Ways and Means Republicans Take Historic Action to Repeal Obamacare & Ensure More Americans Have Access to Affordable Care," accessed March 9, 2017
  54. ↑ Congress.gov, "S.191 - Patient Freedom Act of 2017," accessed March 13, 2017
  55. ↑ Collins.Senate.gov, "Cassidy, Collins Release Legislative Text for Obamacare Replacement Plan," accessed March 13, 2017
  56. ↑ The Wall Street Journal, "GOP Senators Propose Health Law Replacement That Lets States Opt Out," accessed March 13, 2017
  57. ↑ Clerk.House.gov, "Final Vote Results for Roll Call 59," accessed January 13, 2017
  58. ↑ Senate.gov, "On the Concurrent Resolution (S. Con. Res. 3)," accessed January 13, 2017
  59. ↑ USA Today, "Sen. Rand Paul using Obamacare repeal to protest debt," accessed January 13, 2017
  60. ↑ Congress.gov, "S.Con.Res.3," accessed January 6, 2017
  61. ↑ Senate.gov, "On the Motion to Proceed (Motion to Proceed to S. Con. Res. 3)," accessed January 6, 2017
  62. ↑ 62.0 62.1 The New York Times, "$8 Billion Deal Gives Crucial Momentum to G.O.P. Health Bill," May 3, 2017
  63. ↑ House Committee on Rules, "Amendment to HR 1628 As Reported - April 6," accessed May 15, 2017
  64. ↑ The Hill, "Key GOP reps will back ObamaCare repeal bill with new amendment," May 3, 2017
  65. ↑ Politico, "White House plans Obamacare showdown next week," April 20, 2017
  66. ↑ National Association of Insurance Commissioners, "Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges," April 20, 2010
  67. ↑ House Committee on Rules, "Amendment #33 offered by the Hon. Thomas MacArthur," accessed May 17, 2017
  68. ↑ The Hill, "Live coverage: Trump, GOP scramble for ObamaCare votes," March 24, 2017
  69. ↑ Washington Post, "This is why Obamacare is canceling some people's insurance plans," October 29, 2013
  70. ↑ Politico, "GOP leaders pile on sweeteners to sell Obamacare repeal," March 20, 2017
  71. ↑ GovTrack, "H.R. 3590 (111th): Patient Protection and Affordable Care Act," December 24, 2009
  72. ↑ GovTrack, "H.R. 3590 (111th): Patient Protection and Affordable Care Act," March 21, 2010
  73. ↑ Pelosi.House.gov, "Pelosi Statement on HHS Report Showing Continued Affordability of ACA Marketplace Health Coverage," accessed November 28, 2016
  74. ↑ RepublicanLeader.Senate.gov, "McConnell: Obamacare is failing the Middle Class," accessed November 28, 2016
  75. ↑ The Hill, "House passes ObamaCare repeal, sending measure to president," January 6, 2016
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115th Congress, 2017-2018, Issues
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