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

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Domestic policy Key votes • Energy and the environment • Healthcare • Immigration

Economic policy and government regulations Key votes • Budget • Financial policy • Taxes • Trade

Foreign policy and national security Key votes • Iran nuclear deal

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This page outlines the debate about the American Health Care Act of 2017 (AHCA) through March 2017. For information on the AHCA after March 2017, please visit: 115th Congress on the American Health Care Act of 2017 (May, revised AHCA bill).

On March 6, 2017, House Republicans introduced 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. The bill did not propose repealing the ACA in its entirety, a move that was criticized by some conservatives who called for a full repeal of President Barack Obama's signature healthcare law.

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 end, as would 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.

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to the bill—one that would have allowed work requirements and block grants in Medicaid, and another that would have repealed the ACA’s essential benefits provision—did little to garner support among Republicans in opposition.

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.

What did members of Congress think about the AHCA?

115th Congress, 2017-2018 Healthcare policy

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

Reps. Kevin Brady (R-Texas) and Greg Walden (R-Ore.), the bill's sponsors, wrote in an op-ed that the AHCA "will rescue those hurt by ObamaCare’s failures and lay the groundwork for a patient-centered health-care system. ... After seven years of ObamaCare’s failures, Republicans are committed to lowering costs, expanding choices and putting the American people back in charge of their own health care."

Conservative and libertarian-leaning Republicans—led by members of the House Freedom Caucus, the Republican Study Committee, and Sen. Rand Paul (R-Ky.)—criticized the AHCA because it would not have fully repealed the ACA, included an extended period for the Medicaid expansion, and replaced income-based subsidies in the ACA with age-based tax credits, which they said was a new entitlement. Some Republicans in the Senate criticized the bill because they opposed the changes to Medicaid. Sens. Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) criticized the bill because it proposed defunding organizations like Planned Parenthood that provided women's healthcare services, as well as abortion services.

Speaker of the House Paul Ryan (R-Wis.) and Reps. Walden and Brady countered opposition in their party by explaining that they wanted to make additional changes to the healthcare system but that they had to put forward a bill that had a chance of passing the Senate. Walden said that passing a full repeal of the ACA would require support from Democrats, but Democrats said that they were strongly opposed to a full repeal. Because a repeal bill would not have met the 60-vote threshold, Walden and Brady proposed a reconciliation bill that would have only needed a simple majority to pass in the Senate. Walden said, “Part of what we’re getting criticized for is what’s not in this bill. There are a lot of things that we will do going forward in the next bucket that we are prohibited from putting in this bill because of the rules of the Senate on reconciliation. So we could load this thing up, but then you got to get 60 votes in the Senate. You can get 60 votes in the Senate, I’m all for doing more. I want to get as much reform as I can here. This is the start. This is one piece.”

No Democratic members of Congress expressed support for the AHCA. House Minority Leader Nancy Pelosi (D-Calif.) said the bill "hands billionaires a massive new tax break while shifting huge costs and burdens onto working families across America." Senate Minority Leader Chuck Schumer (D-N.Y.) said the bill "would cut and cap Medicaid, defund Planned Parenthood, and force Americans, particularly older Americans, to pay more out of pocket for their medical care all so insurance companies can pad their bottom line."

Click here to read more about the American Health Care Act of 2017.

Responses to the withdrawal of the AHCA

President Donald Trump initially blamed the failure to hold a vote on the AHCA on the Democrats, saying, “With no Democrat support, we couldn't quite get there. We were just a very small number of votes short in terms of getting our bill passed.” He then said that he thought Democrats would seek to compromise following a significant rise in premiums under the ACA. “I honestly believe the Democrats will come to us and say, look, let's get together and get a great healthcare bill or plan that's really great for the people of our country. And I think that's going to happen,” he said.

House Minority Leader Nancy Pelosi (D-Calif.) called the bill’s withdrawal a “victory for the American people.” She emphasized the unity of the Democratic Party, saying, “It's about our country and the vision of our founders. It's about our faith, and it's about the unity of the Democrats, united by our values.”

On March 28, 2017, Senate Majority Leader Mitch McConnell (R-Ky.) said, "It’s pretty obvious we were not able in the House to pass a replacement. Our Democratic friends ought to be pretty happy about that because we have the existing law in place and I think we’re just going to have to see how that works out. We believe it will not work out well, but we’ll see. They have an opportunity now to have the status quo go forward, regretfully. I want to thank the president and the Speaker, they went all out to try to pass a repeal and replacement. I’m sorry that didn’t work, but our Democratic friends now have the law that they wrote in place, and we’ll see how that works out."

On the same day, Senate Minority Leader Chuck Schumer (D-N.Y.) said, "I would say to the Speaker, to Leader McConnell and to the president: Drop repeal. Drop it today and drop it for good. Stop undermining the ACA. Once those things are done, we Democrats are more than happy to sit down together and come up with ways to make it better."

House Freedom Caucus

The primary Republican opposition to the AHCA came from the House Freedom Caucus, a coalition of approximately 35 to 40 lawmakers who promoted what they consider limited government, the rule of law, liberty, safety, and prosperity.

Asked if he felt betrayed by the Freedom Caucus, Trump said, “They're friends of mine. I'm disappointed because we could have had it. So I'm disappointed. I'm a little surprised, to be honest with you. We really had it. It was pretty much there within grasp.”

However, on March 26, 2017, Trump tweeted that the Freedom Caucus was one of the groups responsible for the bill’s failure. “Democrats are smiling in D.C. that the Freedom Caucus, with the help of Club For Growth and Heritage, have saved Planned Parenthood & Ocare,” he wrote.

Shortly after, Rep. Ted Poe (R-Texas), who was leaning in support of the bill, resigned from the caucus. He said in a statement, “In order to deliver on the conservative agenda we have promised the American people for eight years, we must come together to find solutions to move this country forward. Saying no is easy, leading is hard, but that is what we were elected to do. Leaving this caucus will allow me to be a more effective Member of Congress and advocate for the people of Texas. It is time to lead.”

Republicans' positions on the AHCA

For detailed information on Republicans who were likely to oppose the AHCA, click here.

Comments from members of Congress on the AHCA

House Republicans who expressed support for the American Health Care Act of 2017
Name	State	Date	Statement
Rep. Gary Palmer	Alabama's 6th Congressional District	March 17, 2017 March 16, 2017	On March 17, 2017, after President Donald Trump said that he supported the proposed changes to Medicaid that would allow states to accept a fixed block grant instead of the per-person reimbursement and create a work requirement to receive Medicaid benefits, Palmer said that he would vote for the bill. On March 16, 2017, Palmer voted against advancing the AHCA in the House Budget Committee.
House Majority Whip Steve Scalise	Louisiana's 1st Congressional District	March 9, 2017	"At the end of the day, members are going to have to make a choice: Do they want to vote with Nancy Pelosi or do they want to support President Trump to get that bill to his desk?"
Chairman of the Republican Study Committee Rep. Mark Walker	North Carolina's 6th Congressional District	March 16, 2017	After meeting with President Donald Trump, Walker said, “We appreciate the opportunity to discuss with the president the best ways forward to repeal and replace Obamacare. For over six weeks, we’ve been working with the White House, House leadership, congressional committees and members of the Republican Study Committee to address conservative concerns and make the bill better for the American people. Based on our conversations with the president, several measures to improve the bill will be added in the final product, including: Providing states with the option to block grant Medicaid; Implementing work requirements for Medicaid recipients who are able-bodied and without dependents; and Protecting the unborn by ensuring that tax credits in the bill cannot be used to pay for abortions. On balance and with the changes we agreed to in the bill’s final text, I can vote for it. We will continue working to advocate changes to the bill, and hope the legislation improves in the Senate. At the end of the day, we are all committed to repealing Obamacare.”
Rep. Diane Black	Tennessee's 6th Congressional District	March 16, 2017	Before the House Budget Committee voted to advance the AHCA, Black said, "To my Republican colleagues who have doubts today, I encourage you: Don't cut off discussion. Stay in this effort and help us enhance this proposal by advancing it out of committee and pushing for further conservative reforms."
Rep. Kevin Brady	Texas' 8th Congressional District	March 8, 2017	"With the American Health Care Act, House Republicans are answering President Trump’s call to action. We are sending a clear signal to people in Texas and across the country: Relief is on the way. Our legislation dismantles Obamacare’s harmful taxes and mandates. It enhances choice and control for the American people by expanding health savings accounts. It protects health insurance for workers who get coverage through their jobs. It empowers states to strengthen Medicaid and develop new programs that better serve their populations. And, for Americans who don’t get insurance through work or a federal program, we provide a tax credit to help purchase coverage tailored to your needs."
Rep. Tom Cole	Oklahoma's 4th Congressional District	March 13, 2017	"I am sure that as it [the AHCA] moves through the committee process this replacement will be refined and improved. But even in its beginning stages, this legislation is an improvement over Obamacare. Almost anything would be."
Rep. Greg Walden	Oregon's 2nd Congressional District	March 9, 2017	"More than eight months ago House Republicans unveiled a Better Way, which included our vision for repealing Obamacare and replacing it with a patient-centered, 21st century health care system. Today we begin the process of implementing that vision,” said Walden. “After years of Obamacare's broken promises we're proud to put forth a plan that presents a better way for patients, and for families. Let me be clear, under our plan we are not going backward – we are going forward. We are protecting those patients living with pre-existing conditions. We're not returning to the days of lifetime caps or annual limits. We will continue to allow young adults to remain on their parents’ policies until age 26. We will keep our promise to not pull the rug out from anyone as we transition away from this failing law. Under our plan, we're moving forward. We're moving away from a government-run system that is in collapse, and where bureaucrats stand in the way between patients and their doctors. Instead we move forward toward a health care system where one-size-fits-all mandates are a thing of the past. Where states are empowered to innovate and care for their citizens and, most importantly, where patients are actually in charge."
Speaker of the House Paul Ryan	Wisconsin's 1st Congressional District	March 8, 2017	“This is what good, conservative health-care reform looks like. It is bold and long overdue. And it is us fulfilling our promises.”

House Republicans who expressed opposition to the American Health Care Act of 2017
Name	State	Date	Statement
Rep. Darrell Issa	California's 49th Congressional District	March 13, 2017	"I'm not prepared to vote for it [as it] is right now."
Rep. Ted Yoho	Florida's 3rd Congressional District	March 14, 2017	"I could not support the bill as it is right now."
Rep. Ileana Ros-Lehtinen	Florida's 27th Congressional District	March 14, 2017	“After studying the impact of this proposed legislation on my district and speaking with many of my constituents, I have decided to vote no on the bill as currently written. The bill’s consequences for South Florida are clear: too many of my constituents will lose insurance and there will be less funds to help the poor and elderly with their healthcare. I voted to repeal Obamacare many times because it was not the right fix for our broken healthcare system and did not live up to its promise to the American people but this plan is not the replacement South Florida needs. We should work together to write a bipartisan bill that works for our community and our nation without hurting the elderly and disadvantaged among us.”
Rep. Raul Labrador	Idaho's 1st Congressional District	March 9, 2017	"The time is now, the time is today — we need to make sure that we repeal and replace ObamaCare. But this bill is not it."
Rep. Thomas Massie	Kentucky's 4th Congressional District	March 7, 2017	Massie said the healthcare law was "a stinking pile of garbage." He added, "I think the [American Healthcare Act] was written by the same people that wrote Obamacare. That's why it looks so similar. It was the insurance lobby."
Rep. Justin Amash	Michigan's 3rd Congressional District	March 20, 2017 March 7, 2017	"While I've been in Congress, I can't recall a more universally detested piece of legislation than this GOP health care bill." "New plan does not repeal/replace; it repackages Obamacare. It's a political plan that signals retreat and will not reduce health care costs. ... Dear @POTUS, There's nothing 'wonderful' about GOP plan. It repackages Obamacare, breaks promises & doesn't lower costs. Sincerely, Justin."
Rep. John Katko	New York's 24th Congressional District	March 17, 2017	"Despite some promising reforms, I do not support the proposal before the House in its current form. This bill represents only the first step of a long process of healthcare reform and it is not at all clear what the final form will look like. Substantial future administrative and legislative action would be needed. Fundamentally, I don't believe this proposal provides an adequate market-based option for insurance access, nor does it address out-of-control costs. Further, I am confident the proposal would harm hospitals across my district. Hurting New York State, to benefit other regions does not sit well with me."
Chairman of the House Freedom Caucus Rep. Mark Meadows	North Carolina's 11th Congressional District	March 6, 2017	"We call on Congressional leaders to keep their word to the American people, to push a real repeal of ObamaCare, and to do it now. The only way to really do that in a way that ensures passage is to move forward with a 'clean' repeal, such as the 2015 repeal bill. ... If anyone tells you there isn’t a plan that can both keep our promises to repeal, and work in a bipartisan, open way for replace, tell them conservatives have a plan to do just that. Now let’s hope our leadership will listen, because it is the only way they’re going to get our votes."
Rep. Jim Jordan	Ohio's 7th Congressional District	March 8, 2017 March 6, 2017	"Even if you don’t have the CBO score, look at the four corners of the document and read what it says. I think it’s not going to bring down the cost of premiums for working class and middle class families. That’s why I oppose it. I think it’s Obamacare, as I’ve said, Obamacare in a different form. That’s why I oppose it. But it would also be nice to have a score. I can’t believe the score won’t be high because, when you’re extending and expanding the Medicaid expansion, when you’re starting this new entitlement called advanceable refundable tax credits, when you’re doing all that, I’ve got to believe that’s a cost to the federal government. But apart from that, just look at what it does, it keeps the federal government in control of how this thing works, the exchange and that sort of thing. That’s the wrong approach because we’ve seen how bad Obamacare has been for the American people the last six years." “This is Obamacare by a different form. They’re still keeping the taxes in place and Medicaid expansion, and they’re starting a new entitlement.”
Rep. Warren Davidson	Ohio's 8th Congressional District	March 16, 2017	"It is an amendment to the Affordable Care Act. It's constrained due to the rules of the budget. And I think a lot of people are very concerned that when they see this, this is what we're going to accomplish. And that falls far short of what we promised voters. ... If we called the votes today, I would be a no, as would a lot of other people in the Congress today. And that's the House. From what I hear, the Senate's in even more turmoil in terms of whether they could support this. So this bill as it stands needs to be improved just to pass. But fundamentally it needs to be improved to deliver on the promise we made voters."
Rep. Brian Fitzpatrick	Pennsylvania's 8th Congressional District	March 18, 2017	"After considering the current healthcare bill in a thorough and deliberate manner, I have concluded that, although the American Health Care Act focuses on several much-needed reforms to our healthcare system, in its current form I cannot support this legislation. I have many concerns with this bill, and first among them is the impact on the single most important issue plaguing Bucks and Montgomery Counties, and the issue that I have made my priority in Congress: opioid abuse prevention, treatment and recovery."
Rep. Mark Sanford	South Carolina's 1st Congressional District	March 16, 2017	Sanford voted against advancing the AHCA in the House Budget Committee.
Rep. Rob Wittman	Virginia's 1st Congressional District	March 13, 2017	"After reviewing this legislation and receiving the Congressional Budget Office score today, it is clear that this bill is not consistent with the repeal and replace principles for which I stand. I do not think this bill will do what is necessary for the short and long-term best interests of Virginians and therefore, I must oppose it. I do believe that we can enact meaningful health care reforms that put the patient and health care provider back at the center of our health care system, but this bill is not the right answer. This doesn’t change the fact that we need to repeal Obamacare, as I have voted to do. I stand ready and willing to work with my colleagues on legislation that expands choices, increases access, and reduces costs.”
Rep. Tom Garrett	Virginia's 5th Congressional District	March 14, 2017	“Right now I’m a no. I’m a firm no.”
Rep. David Brat	Virginia's 7th Congressional District	March 7, 2017	"Well, no, I can't support it because if you look at what went wrong with Obamacare, ACA - right? - it was a federally run program that's now in a death spiral, and anyone could see that eight years ago. And so you have to design a program that works in the first place, right? So the first hint - when those insurance titans of industry went in to the White House eight years ago, they were looking at their shoes. They couldn't look at your cameras because they were embarrassed about the product. They were getting 18 million more people covered, but they knew they had a system that didn't work. And so the last thing we need to do is replicate a system that doesn't work. And what do I mean by that? It's going to be federally run system, right? It's going to create a new entitlement program - and I'll get to that in a minute if we have time to - what that all means. It keeps the insurance regulations. The expansion of Medicaid - it's not clear, but it goes off for about eight more years. And it basically keeps too many of the bad pieces which will collide with each other, and it will collapse, right? And so... We didn't run on this however (ph). We voted on the 2015 plan through the House and the Senate, which was a repeal. And all of a sudden, all this new stuff at the federal level comes up and is clouding the picture."

Senate Republicans who expressed opposition to the American Health Care Act of 2017
Name	State	Date	Statement
Sen. Rand Paul	Kentucky	March 6, 2017	"We call on Congressional leaders to keep their word to the American people, to push a real repeal of ObamaCare, and to do it now. The only way to really do that in a way that ensures passage is to move forward with a 'clean' repeal, such as the 2015 repeal bill. ... If anyone tells you there isn’t a plan that can both keep our promises to repeal, and work in a bipartisan, open way for replace, tell them conservatives have a plan to do just that. Now let’s hope our leadership will listen, because it is the only way they’re going to get our votes."
Sen. Susan Collins	Maine	March 16, 2017 March 8, 2017	“This is not a bill I could support in its current form. It really misses the mark. ... This bill doesn’t come close to achieving the goal of allowing low-income seniors to purchase health insurance. We don’t want to in any way sacrifice coverage for people who need it the most. ... Older people living in rural America would be really left behind." When asked about the AHCA, Collins said, "I do not think it would be well received in the Senate." According to Yahoo News, "The Maine senator also strongly opposes defunding women’s health services and abortion provider Planned Parenthood in any health care bill, since 10,000 women in her state use Planned Parenthood for cancer screenings and other health care." Collins said, "Where are those people going to go? And why should those women have to change doctors? That doesn’t make sense."
Sen. Dean Heller	Nevada	March 17, 2017	According to The Washington Post, "Heller’s spokesman Mac Abrams said Friday that the senator said he can’t support the bill as the House GOP has crafted it."
Sen. Ted Cruz	Texas	March 19, 2017 March 9, 2017 March 8, 2017	“I cannot vote for any bill that keeps premiums rising. ... My biggest concern with the House bill is it doesn’t lower premiums. And [the Congressional Budget Office] in fact projected that in the first two years premiums would rise 10 to 20 percent. ... I do not believe it will pass the Senate. ... I’ve got to tell you, if Republicans hold a big press conference and pat ourselves on the back that we’ve repealed Obamacare and everyone’s premiums keep going up, people will be ready to tar and feather us in the streets. And quite rightly.” Cruz said that Vice President Mike Pence should overrule the Senate's parliamentarian on what is allowed in a reconciliation bill so that the GOP could expand the scope of the AHCA. He said, “Under the Budget Act of 1974, which is what governs reconciliation, it is the presiding officer, the vice president of the United States, who rules on what’s permissible on reconciliation and what is not. That’s a conversation I’ve been having with a number of my colleagues." "The current draft in the House is a draft about which I have significant concerns. As drafted, I do not believe this bill would pass the United States Senate. But I am encouraged and optimistic that we can resolve these differences."
Sen. Mike Lee	Utah	March 7, 2017	"This is not the Obamacare repeal bill we’ve been waiting for. It is a missed opportunity and a step in the wrong direction. We promised the American people we would drain the swamp and end business as usual in Washington. This bill does not do that. We don’t know how many people would use this new tax credit, we don’t know how much it will cost, and we don’t know if this bill will make health care more affordable for Americans. This is exactly the type of back-room dealing and rushed process that we criticized Democrats for and it is not what we promised the American people. Let’s fulfill our Obamacare repeal promise immediately and then take our time and do reform right. Let’s pass the 2015 repeal bill that Republicans in both houses of Congress voted for and sent to the White House just 15 months ago. Once Obamacare has been properly sent to the dustbin of history then we can begin a deliberative, open, and honest process to reform our nation’s health care system."

Senate Republicans who are undecided/want changes made to the American Health Care Act of 2017
Name	State	Date	Statement
Sen. Lisa Murkowski	Alaska	March 2017	Murkowski said that she opposed the measure to defund Planned Parenthood in the AHCA, but she did not rule out voting in favor of the bill. She said, "I have said continuously and repeatedly that I support the work of Planned Parenthood. I support the continuation of Medicaid funding going to them. I’m not saying anything is a deal-breaker, but I am making very, very clear my position." Murkowski also signed a letter stating that she would not support the AHCA if it included plans to phase out the Medicaid expansion.
Sen. Tom Cotton	Arkansas	March 9, 2017	In a series of tweets, Cotton wrote, "1. House health-care bill can't pass Senate w/o major changes. To my friends in House: pause, start over. Get it right, don't get it fast. ... 2. GOP shouldn't act like Dems did in O'care. No excuse to release bill Mon night, start voting Wed. With no budget estimate! ... 3. What matters in long run is better, more affordable health care for Americans, NOT House leaders' arbitrary legislative calendar."
Sen. Cory Gardner	Colorado	March 6, 2017	In a letter to Senate Majority Leader Mitch McConnell (R-Ky.), a group of senators said, "[W]e will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states."
Sen. Bill Cassidy	Louisiana	March 14, 2017	After the CBO report was released, Cassidy said, "It's awful. It has to be a concern. President Trump said he wanted as many people covered as under Obamacare."
Sen. Steve Daines	Montana	March 15, 2017	After the CBO report was released, Daines said, "We need to do better. I want to see costs and premiums go down to make health care more affordable for Montana families."
Sen. Rob Portman	Ohio	March 6, 2017	In a letter to Senate Majority Leader Mitch McConnell (R-Ky.), a group of senators said, "[W]e will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states."
Sen. Shelley Moore Capito	West Virginia	March 6, 2017	In a letter to Senate Majority Leader Mitch McConnell (R-Ky.), a group of senators said, "[W]e will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states."

Proposed changes to the AHCA

Negotiations

On March 11, 2017, House Freedom Caucus Chairman Mark Meadows (R-N.C.) and Rep. Justin Amash (R-Mich.) said that although GOP leadership seemed unwilling to consider changes to the AHCA, the Trump administration signaled that it was open to negotiations. Meadows told The Hill that the Trump administration was “still willing to negotiate in good faith; that has been reaffirmed time after time.”

Amash said, “President Trump isn’t as committed to one policy approach as the leadership team is. The leadership team seems to be very committed to this particular approach. And I think the White House just wants to get something done that will fulfill the promise the president made to repeal and replace.”

On March 19, 2017, Speaker of the House Paul Ryan (R-Wis.) said that Trump had been helpful during the negotiation process. He said, “The reason why I feel good about it [the healthcare bill passing the house] is because the president has become a great closer. He is the one who has helped to negotiate the changes to this bill with members from all over our caucus. I call it getting the sweet spot.”

Medicaid

The Republican Study Committee (RSC) proposed an amendment to the AHCA that would end Medicaid expansion in 2018 instead of 2020. If the House passed the amendment, it would likely fail in the Senate because a group of senators—Rob Portman (R-Ohio), Shelley Moore Capito (R-W.Va.), Cory Gardner (R-Colo.), and Lisa Murkowski (R-Alaska)—said that they would not support a measure that created instability for citizens on Medicaid.

On March 17, 2017, after a meeting with members of the RSC, Trump said that he supported allowing states to impose work requirements on childless adults receiving Medicaid benefits. He also expressed his support for allowing states to accept a fixed block grant instead of a per-person reimbursement. By backing these reforms to Medicaid, Trump earned the support of some members of the RSC. Trump said, “I want to let the world know: I am 100 percent in favor. These folks were no’s, mostly no’s yesterday, and now every single one is a yes.”

After the meeting, Rep. Phil Roe (R-Tenn.) said, “The core of the conference wants to get to yes. We’re closer than we were a week ago, I’ll tell you that.”

March 20, 2017, amendment: Tax credits, Medicaid, and ACA taxes

On March 20, 2017, the House added an amendment to the bill 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 also 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 block grants if they chose. Finally, 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.

Essential health benefits provision (mandated healthcare services)

According to The Hill, House Freedom Caucus members "want the bill to repeal ObamaCare’s 'essential health benefits,' which mandate healthcare services that plans must cover, as well as ObamaCare’s insurance regulations, like the ban on discriminating against people with pre-existing conditions. Conservatives say that if those requirements were repealed, insurers could offer cheaper plans that cover less. Right now, they say, the GOP bill could actually raise premiums."

Amending the bill to eliminate the ACA's essential health benefits would likely have prevented the Senate from voting on the bill through the reconciliation process, which only required a simple majority to pass legislation. The amended bill would have required 60 votes to pass. In this scenario, Republicans would have needed Democrats to vote in favor of the bill, but no Democratic members of Congress supported repealing the ACA.

On 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. The ACA specified the following 10 essential benefits that plans created after the law's passage needed to cover:

• 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

Under the amendment, each state instead would have been required to determine which essential benefits insurers licensed in that state had to 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.

Helping individuals in their 50s and 60s

The CBO report indicated that individuals in their 50s and 60s would see increases in their premiums in 10 years. Speaker of the House Paul Ryan (R-Wis.) commented on the increases, saying, “We believe we should have more assistance, and that’s what we are looking at, for that person in their 50s and 60s because they experience higher health-care costs."

Congressional Budget Office report on the AHCA

On March 13, 2017, the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) released a report estimating the cost of the AHCA and its impact on the number of uninsured. The key findings appear below.

• Federal budget: The AHCA would reduce federal deficits by $337 billion over the 2017 to 2026 period due to a $1.2 trillion decrease in direct spending, partially offset by an $883 billion reduction in revenues.

• Savings would come from reducing Medicaid funding and eliminating ACA subsidies for nongroup health insurance.

• Costs would come from changes to the tax code, the Patient and State Stability Fund grant program, and increased spending under Medicare. According to the report, "The largest costs would come from repealing many of the changes the ACA made to the Internal Revenue Code—including an increase in the Hospital Insurance payroll tax rate for high-income taxpayers, a surtax on those taxpayers’ net investment income, and annual fees imposed on health insurers—and from the establishment of a new tax credit for health insurance."

• Health insurance coverage: Compared to the ACA, 14 million more people would be uninsured in 2018 under the AHCA, and 24 million more people would be uninsured in 2026. In total, under the AHCA, 52 million people would be uninsured in 2026, compared to 28 million who would be uninsured under the ACA.

• Increases in the number of uninsured would come from repealing the penalties associated with the individual mandate and changes to subsidies and Medicaid.

• Stability of the health insurance market: The market for insurance purchased individually would remain stable under the AHCA because of subsidies to purchase insurance and grants to states from the Patient and State Stability Fund. According to the report, "Even though the new tax credits would be structured differently from the current subsidies and would generally be less generous for those receiving subsidies under current law, the other changes would, in the agencies’ view, lower average premiums enough to attract a sufficient number of relatively healthy people to stabilize the market."

• Effects on premiums: The AHCA would initially increase average premiums in the nongroup market by 15 to 20 percent and then lower average premiums in 2020 compared to projections under the ACA. By 2026, average premiums for single policyholders in the nongroup market would be 10 percent lower than under the ACA.

• The initial rise in premiums would result from the elimination of the individual mandate penalties, which would likely result in healthier individuals leaving the health insurance market. "Starting in 2020, the increase in average premiums from repealing the individual mandate penalties would be more than offset by the combination of several factors that would decrease those premiums: grants to states from the Patient and State Stability Fund; the elimination of the requirement for insurers to offer plans covering certain percentages of the cost of covered benefits; and a younger mix of enrollees," according to the report. The CBO and JCT estimated that premiums would be lower for younger people and higher for older people under the AHCA.

Reactions to CBO report

• Secretary of Health and Human Services Tom Price commented on the CBO's report, saying, “We disagree strenuously with the report that was put out. We believe that our plan will cover more individuals at a lower cost and give them the choices that they want for the coverage that they want for themselves and for their families, not that the government forces them to buy. ... It’s about the coverage — the health coverage — that they have but the health care that they receive. And the fact of the matter is that right now, current law, we’ve got individuals who have health coverage but no health care. And it’s incredibly important to appreciate that. In fact, the care — the coverage numbers are, in fact, going down. If Obamacare — if the ACA went away, the fact of the matter is that there would be 20 million who would not have coverage. ... The entire plan includes the regulatory apparatus that we’ve got the ability to use at Health and Human Services that the previous administration used significantly. But we want to use it to make certain that patients are helped and that costs are decreased. They also ignored completely the other legislative activities that we’ll be putting into place that will make certain that we have an insurance market that actually works.”

• Sen. Lindsey Graham (R-S.C.) said, “Let’s say the CBO is half right—that should be cause for concern. The prudent thing for the party to do is to look at the CBO report and see if we can address some of the concerns raised.”

• Sen. Bernie Sanders (I-Vt.) said, “In the year 2017, Republicans want to throw 24 million people off health insurance, raise premiums for older people, and at the same time provide $285 billion in tax breaks for the top 2%. I think that legislation is disgusting, it is immoral, and it should not see the light of day.”

Outside groups and influencers on the AHCA

Support

American Action Network, "Tell Congressman Labrador to Support the American Health Care Act," March 9, 2015

• American Action Network - The American Action Network, a group aligned with Speaker Paul Ryan (R-Wis.), spent $500,000 to run ads that ask the constituents of members of the Freedom Caucus to vote for the AHCA.

• U.S. Chamber of Commerce - Neil Bradley, the U.S. Chamber's senior vice president and chief policy officer, wrote the following in a letter to the Energy and Commerce and Ways and Means Committees: "The U.S. Chamber of Commerce supports the 2017 House Reconciliation Legislative Recommendations. Critically important provisions in the Recommendations repeal a substantial number of the most harmful provisions in the Affordable Care Act: the health insurance tax, the medical device tax, and the tax on prescription medications; restrictions on the use and limitations on contributions to health savings accounts and flexible spending accounts; and the penalties associated with the employer mandate. Just as importantly, the Recommendations preserve the longstanding tax treatment of employer sponsored coverage through which 177 million individuals receive their health care coverage. The Chamber is also pleased that the House is proposing to delay the 40 percent Cadillac tax, and we look forward to working with Congress to eventually repeal the tax completely. These Recommendations and the successful mark-up of the provisions in the Ways and Means and Energy and Commerce Committees tomorrow are absolutely critical in taking steps to restore choice, flexibility and innovation to the nation’s health care markets. The Chamber looks forward to working with the House and Senate to refine and advance these and other important reform proposals."

• The Wall Street Journal editorial board - "The American Health Care Act would be the most consequential GOP social-policy reform since the welfare overhaul of 1996. Not only does the bill repair the failures of the Affordable Care Act, it starts to correct many of the government-created dysfunctions that have bedeviled U.S. health care for decades."

Oppose

• Heritage Action - Michael Needham, chief executive of Heritage Action, said, "To the extent that they’re doing something else with this plan other than full repeal, the concerns that conservatives in the House are expressing are completely valid."

• Club for Growth

• Freedom Partners: Nathan Nascimento, Freedom Partners’ vice president of policy, said, "Fully repealing Obamacare needs to be Congress’ top priority, but raising taxes to create a new entitlement in its place keeps Washington at the center of our health-care system and leaves Obamacare’s crumbling foundation largely intact."

• American Medical Association - Dr. Andrew Gurman, president of the American Medical Association (AMA), wrote in a letter to Congress, “As drafted, the AHCA would result in millions of Americans losing coverage and benefits. By replacing income-based premium subsidies with age-based tax credits, the AHCA will also make coverage more expensive — if not out of reach — for poor and sick Americans. For these reasons, the AMA cannot support the AHCA as it is currently written. ... We encourage you to ensure that low and moderate income Americans will be able to secure affordable and adequate coverage and that Medicaid, [Children's Health Insurance Program], and other safety net programs are maintained and adequately funded. And critically, we urge you to do all that is possible to ensure that those who are currently covered do not become uninsured.”

• The American Hospital Association - Richard Pollack, the president and CEO of the American Hospital Association, wrote in a letter to House Republicans, “We ask Congress to protect our patients, and find ways to maintain coverage for as many Americans as possible. We look forward to continuing to work with the Congress and the Administration on [Affordable Care Act] ACA reform, but we cannot support The American Health Care Act in its current form. If coverage is not maintained at the current level, those resources need to be returned to hospitals and health systems in order to provide services to what will likely be an increased number of uninsured Americans. The expanded use of waivers with appropriate safeguards can be very effective in allowing state flexibility to foster creative approaches and can improve the program more effectively than through imposing per-capita caps. We urge that Congress should wait until an estimate is available before proceeding with a formal consideration. ... We believe that any changes to the [Affordable Care Act] must be guided by ensuring that we continue to provide health care coverage for the tens of millions of Americans who have benefitted from the law. ... We are pleased that so many in Congress also recognize the need to preserve patient coverage. ... We believe the legislation needs to be reviewed through this lens, and carefully evaluated regarding its impact on both individuals and the ability of hospitals and health systems which are the backbone of the nation's health care safety net in terms of our ability to care for all of those who walk through our doors."

• America’s Essential Hospitals - Dr. Bruce Siegel, president and chief executive of AEH, said in the letter, “America’s Essential Hospitals cannot support the legislation to be considered by the committee."

• America’s Health Insurance Plans

• The Cato Institute’s Michael Cannon - Cannon called it “a train wreck waiting to happen. ... It is remarkable that they’ve produced a bill that is so out of touch with ACA opponents. The first rule in these situations is you want to dance with the gal that brung ya. You don’t want to walk away from your base.”

Timeline of ACA repeal and replace efforts

See also: Alternative proposals to the Affordable Care Act (Obamacare)

• March 24, 2017: House Republican leaders withdrew the bill amid dwindling support.

• March 16, 2017: The United States House of Representatives Committee on the Budget voted 19-17 to approve the AHCA. Three Republicans—Reps. David Brat (Va.), Mark Sanford (S.C.), and Gary Palmer (Ala.)—voted against advancing the bill.

• March 9, 2017: The United States House of Representatives Committee on Energy and Commerce approved the AHCA.

• March 9, 2017: The United States House of Representatives Committee on Ways and Means approved the AHCA.

• 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.

• 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.

• 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.’"

• January 13, 2017: The House passed S Con Res 3, a budget resolution to begin rolling back the ACA, by a vote of 227-198. Nine Republicans joined every Democratic member of the House to vote against the budget resolution. The nine Republicans were: Justin Amash (Mich.), Charlie Dent (Pa.), Brian Fitzpatrick (Pa.), Walter Jones (N.C.), John Katko (N.Y.), Raul Labrador (Idaho), Thomas Massie (Ky.), Tom MacArthur (N.J.), and Tom McClintock (Calif.).

• 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.”

• 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.

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. With Republicans in control of Congress and the White House, Republican lawmakers are interested in changing President Barack Obama's signature healthcare law.

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.”

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.

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.

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

See also

• 115th Congress on healthcare, 2017-2018
• Federal policy on healthcare, 2017-2020
• American Health Care Act of 2017
• Alternative proposals to the Affordable Care Act (Obamacare)
• Obamacare overview
• Restoring Americans' Healthcare Freedom Reconciliation Act of 2015