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The American Health Care Act of 2017 (often shortened to the AHCA or nicknamed Trumpcare) was a
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in the
115th United States Congress The 115th United States Congress was a meeting of the legislative branch of the United States of America federal government, composed of the Senate and the House of Representatives. It met in Washington, D.C., from January 3, 2017, to January ...
. The bill, which was passed by the
United States House of Representatives The United States House of Representatives, often referred to as the House of Representatives, the U.S. House, or simply the House, is the lower chamber of the United States Congress, with the Senate being the upper chamber. Together they ...
but not by the
United States Senate The United States Senate is the upper chamber of the United States Congress, with the House of Representatives being the lower chamber. Together they compose the national bicameral legislature of the United States. The composition and po ...
, would have partially repealed the
Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Pres ...
(ACA).
Republican Party Republican Party is a name used by many political parties around the world, though the term most commonly refers to the United States' Republican Party. Republican Party may also refer to: Africa * Republican Party (Liberia) *Republican Party ...
leaders had campaigned on the repeal of the ACA since its passage in 2010, and the
2016 elections The following elections occurred in the year 2016. Africa Benin Republic * 2016 Beninese presidential election 6 March 2016 Cape Verde * 2016 Cape Verdean presidential election 2 October 2016 Chad * 2016 Chadian presidential election 10 ...
gave Republicans unified control of
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and the
presidency A presidency is an administration or the executive, the collective administrative and governmental entity that exists around an office of president of a state or nation. Although often the executive branch of government, and often personified by ...
for the first time since the ACA came into effect. Upon the start of the 115th Congress, Congressional Republicans sought to pass a partial repeal of the ACA using the
reconciliation Reconciliation or reconcile may refer to: Accounting * Reconciliation (accounting) Arts, entertainment, and media Sculpture * ''Reconciliation'' (Josefina de Vasconcellos sculpture), a sculpture by Josefina de Vasconcellos in Coventry Cathedra ...
process, which allows legislation to bypass the Senate
filibuster A filibuster is a political procedure in which one or more members of a legislative body prolong debate on proposed legislation so as to delay or entirely prevent decision. It is sometimes referred to as "talking a bill to death" or "talking out ...
and pass with a simple majority in the Senate. With the support of President
Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who served as the 45th president of the United States from 2017 to 2021. Trump graduated from the Wharton School of the University of P ...
, House Republicans introduced the AHCA in early 2017, and the bill passed the House in a close vote on May 4, 2017. All House Democrats, along with several members of the centrist
Tuesday Group The Republican Governance Group, originally the Tuesday Lunch Bunch and then the Tuesday Group until 2020, is a group of moderate Republicans in the United States House of Representatives. It was founded in 1994 in the wake of the Republican tak ...
and some other House Republicans, voted against the AHCA. The bill would have repealed the
individual mandate An individual mandate is a requirement by law for certain persons to purchase or otherwise obtain a good or service. United States Militia act The Militia Acts of 1792, based on the Constitution's militia clause (in addition to its affirmativ ...
and the
employer mandate A health insurance mandate is either an employer or individual mandate to obtain private health insurance instead of (or in addition to) a national health insurance plan.D. Andrew Austin, Thomas L. Hungerford (2010). Market Structure of the ...
, dramatically cut
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
spending and eligibility, eliminated tax credits for healthcare costs, abolished some taxes on high earners, and altered rules concerning
pre-existing condition In the context of healthcare in the United States, a pre-existing condition is a medical condition that started before a person's health insurance went into effect. Before 2014, some insurance policies would not cover expenses due to pre-existi ...
s and
essential health benefits In the United States, essential health benefits (EHBs) are a set of ten benefits, defined under the Affordable Care Act (ACA) of 2010, that must be covered by individually-purchased health insurance and plans in small-group markets both inside and ...
. Senate Republicans initially sought to pass the Better Care Reconciliation Act of 2017 (BCRA), a healthcare bill containing provisions largely similar to those of the AHCA. The BCRA was never voted on in its original form due to opposition from several Republican senators. Senate Majority Leader
Mitch McConnell Addison Mitchell McConnell III (born February 20, 1942) is an American politician and retired attorney serving as the senior United States senator from Kentucky and the Senate minority leader since 2021. Currently in his seventh term, McCon ...
instead sought to pass the Health Care Freedom Act (HCFA), which was colloquially referred to as a "skinny repeal" by Republicans since it would only repeal the individual mandate and the employer mandate. On July 27, the Senate rejected the HCFA in a 51-to-49 vote, with Republican senators
Susan Collins Susan Margaret Collins (born December 7, 1952) is an American politician serving as the senior United States senator from Maine. A member of the Republican Party, she has held her seat since 1997 and is Maine's longest-serving member of Con ...
,
Lisa Murkowski Lisa Ann Murkowski ( ; born May 22, 1957) is an American attorney and politician serving as the senior United States senator for Alaska, having held that seat since 2002. Murkowski is the second-most senior Republican woman in the Senate, after S ...
, and
John McCain John Sidney McCain III (August 29, 1936 – August 25, 2018) was an American politician and United States Navy officer who served as a United States senator from Arizona from 1987 until his death in 2018. He previously served two te ...
joining with all Senate Democrats in voting against it. In September 2017, some Republican senators pushed a renewed effort to repeal the ACA, but their bill never received a vote in the Senate. The 115th Congress ultimately did not pass an ACA repeal bill, though it did pass the
Tax Cuts and Jobs Act of 2017 The Act to provide for reconciliation pursuant to titles II and V of the concurrent resolution on the budget for fiscal year 2018, , is a congressional revenue act of the United States originally introduced in Congress as the Tax Cuts and Jobs A ...
, which repealed the individual mandate. The AHCA was a significant issue in the midterm elections the following year, which saw the election of a Democratic House majority and defeat of several of the bill's supporters for re-election. Members of Congress who voted for the AHCA were more likely to lose their re-election bids. The nonpartisan
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. Ins ...
projected that the AHCA would have increased the number of uninsured people by 23 million over 10 years, but would have decreased the federal budget deficit by $119 billion over the same period. Polling consistently showed that the AHCA was deeply unpopular with the American population during and after its evaluations in Congress. ''
Business Insider ''Insider'', previously named ''Business Insider'' (''BI''), is an American financial and business news website founded in 2007. Since 2015, a majority stake in ''Business Insider''s parent company Insider Inc. has been owned by the German publ ...
'' stated that the AHCA was "the least popular major bill in decades", and major medical organizations, including the
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's sta ...
and the
American Academy of Pediatrics The American Academy of Pediatrics (AAP) is an American professional association of pediatricians, headquartered in Itasca, Illinois. It maintains its Department of Federal Affairs office in Washington, D.C. Background The Academy was found ...
, strongly condemned the bill and excoriated its supporters in Congress.


Background

The ACA (colloquially called "Obamacare"), a major reform of
health care in the United States The United States far outspends any other nation on health care, measured both in ''per capita'' spending and as a percentage of GDP. Despite this, the country has significantly worse healthcare outcomes when compared to peer nations. The Un ...
, was passed in 2010 by the
111th Congress The 111th United States Congress was a meeting of the legislative branch of the United States federal government from January 3, 2009, until January 3, 2011. It began during the last weeks of the George W. Bush administration, with th ...
and signed by President
Barack Obama Barack Hussein Obama II ( ; born August 4, 1961) is an American politician who served as the 44th president of the United States from 2009 to 2017. A member of the Democratic Party (United States), Democratic Party, Obama was the first Af ...
in 2010 after nearly a year of bipartisan debate. The ACA draws from many conservative ideas proposed by the
Heritage Foundation The Heritage Foundation (abbreviated to Heritage) is an American conservative think tank based in Washington, D.C. that is primarily geared toward public policy. The foundation took a leading role in the conservative movement during the preside ...
in the 1980s and 1990s, which included a mandate that all have coverage (to prevent " free riders"), subsidy tax credits, and
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
reform. Heritage proposed funding program costs by taxing health insurance premiums paid by employers on behalf of workers (presently exempt from income), which would have affected all workers covered by employers, while ACA primarily relied on tax rate increases on roughly the top 5% of households. From Obama's inauguration in January 2009 until the November 2010 elections, both houses of Congress and the presidency were controlled by the Democratic Party. During the 2012 presidential election, Republican nominee
Mitt Romney Willard Mitt Romney (born March 12, 1947) is an American politician, businessman, and lawyer serving as the junior United States senator from Utah since January 2019, succeeding Orrin Hatch. He served as the 70th governor of Massachusetts ...
, running against Obama, promised to repeal the ACA, despite its similarity to Romneycare. After Romney's defeat, the ACA remained in effect for the duration of Obama's presidency despite Republican efforts to repeal it. In the
114th Congress The 114th United States Congress was a meeting of the legislative branch of the United States of America federal government, composed of the United States Senate and the United States House of Representatives. It met in Washington, D.C. from Ja ...
, Republicans passed a bill that would have repealed much of the ACA, but the
bill Bill(s) may refer to: Common meanings * Banknote, paper cash (especially in the United States) * Bill (law), a proposed law put before a legislature * Invoice, commercial document issued by a seller to a buyer * Bill, a bird or animal's beak Pla ...
was vetoed by Obama. After winning the 2016 presidential election, President
Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who served as the 45th president of the United States from 2017 to 2021. Trump graduated from the Wharton School of the University of P ...
promised to "repeal and replace" the ACA with a new law. The
2016 elections The following elections occurred in the year 2016. Africa Benin Republic * 2016 Beninese presidential election 6 March 2016 Cape Verde * 2016 Cape Verdean presidential election 2 October 2016 Chad * 2016 Chadian presidential election 10 ...
left Republicans in control of the executive and legislative branches of the U.S. government, but with 52 seats in the 100-member Senate, Republicans would still have to rely on at least some Senate Democrats to overcome a
filibuster A filibuster is a political procedure in which one or more members of a legislative body prolong debate on proposed legislation so as to delay or entirely prevent decision. It is sometimes referred to as "talking a bill to death" or "talking out ...
. However, Senate rules provide for a special budget rule called
reconciliation Reconciliation or reconcile may refer to: Accounting * Reconciliation (accounting) Arts, entertainment, and media Sculpture * ''Reconciliation'' (Josefina de Vasconcellos sculpture), a sculpture by Josefina de Vasconcellos in Coventry Cathedra ...
, which allows certain budget-related bills to bypass the filibuster and be enacted with a simple majority vote. Republican leaders were seeking to pass the AHCA through the Senate by using the reconciliation rule. In 2015, U.S. health care costs were approximately $3.2 trillion, or nearly $10,000 per person on average. Major categories of expense include hospital care (32%), physician and clinical services (20%), and prescription drugs (10%). U.S. costs in 2016 were substantially higher than other OECD countries, at 17.2% GDP versus 12.4% GDP for the next most expensive country (Switzerland). For scale, a 5% GDP difference represents about $1 trillion or $3,000 per person. Some of the many reasons cited for the cost differential with other countries include: Higher administrative costs of a private system with multiple payment processes; higher costs for the same products and services; more expensive volume/mix of services with higher usage of more expensive specialists; aggressive treatment of very sick elderly versus palliative care; less use of government intervention in pricing; and higher income levels driving greater demand for health care. Healthcare costs are a fundamental driver of health insurance costs, which leads to coverage affordability challenges for millions of families. There is ongoing debate whether the current law (ACA/Obamacare) and the Republican alternatives (AHCA and BCRA) do enough to address the cost challenge.


Overview

Both the Republican House AHCA and Senate BCRA bills have proposed major reforms relative to current law (ACA) that would substantially reduce the number of persons covered, moderately lower the budget deficit over a decade, reverse the tax increases on the top 5% (mainly the top 1%), dramatically cut Medicaid payments (25-35%) that benefit lower-income persons, and expand choice by allowing lower quality insurance to be purchased at lower prices for the young and middle-aged. Key provisions of the Republican Senate BCRA take effect over several years and include: *Eliminate employer and individual mandates and related penalties, substituting a one-time premium increase of 30% for persons that were without coverage previously for a specified time period (63 days). *States would be allowed more flexibility in establishing essential health benefits (i.e., insurance policy content). *Change tax credit/subsidy formulas used to help pay for insurance premiums (initially age-based, later modified to income-based) and eliminate a "cost-sharing subsidy" that reduced out-of-pocket costs. *Provide funding to health insurers to stabilize premiums and promote marketplace participation, via a "Long-Term State Stability and Innovation Program" with features analogous to a high-risk pool. *Reduce income ceiling used for Medicaid eligibility and substitute a tax credit for those below 100% of the poverty line. *Reduce Medicaid payments relative to current law, by capping the growth in per-enrollee payments for non-disabled children and non-disabled adults, by using a lower inflation index. *Repeal taxes on high-income earners established under ACA/Obamacare, repeal the annual fee on health insurance providers, and delay the excise tax on high premium health plans (the so-called "Cadillac tax"). *Allow insurers to charge premiums up to five times as much to older people vs. young people, instead of three times, unless the state sets a different limit. *Remove federal cap on the share of premiums that may go to insurers' administrative costs and profits (the "minimum medical loss ratio"). Public opinion regarding the Republican House (AHCA) and Senate (BCRA) bills was very negative (i.e., opposed), with approval ratings between 12 and 38%, and disapproval ratings between 41% and 62%, measured between March and June 2017 (refer to "Specific poll results" table below for sources). Views were split along party lines. For example, the monthly
Kaiser Family Foundation KFF (Kaiser Family Foundation), also known as The Henry J. Kaiser Family Foundation, is an American non-profit organization, headquartered in San Francisco, California. It prefers KFF since its legal name can cause confusion as it is no longer ...
health tracking poll for May 2017 indicated that: * More view the Republican AHCA unfavorably (55%) than favorably (31%). * Views are split along party lines, with % in favor of AHCA: Democrats 8%, Independents 30%, Republicans 67%. * Although historically more people viewed the current law (ACA/"Obamacare") unfavorably than favorably, in May 2017 more had a favorable view (49%) than unfavorable (42%). * More favorably view the ACA/Obamacare (49%) than the Republican AHCA (31%). Health care experts from across the political spectrum – liberal, moderate, and conservative – agreed that the House Republican health care bill was unworkable and suffered from fatal flaws, although specific objections varied depending on ideological perspective. Experts agreed that the bill fell far short of the goals laid forth by
President President most commonly refers to: *President (corporate title) * President (education), a leader of a college or university * President (government title) President may also refer to: Automobiles * Nissan President, a 1966–2010 Japanese ...
Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who served as the 45th president of the United States from 2017 to 2021. Trump graduated from the Wharton School of the University of P ...
during his 2016 campaign – "Affordable coverage for everyone; lower deductibles and health care costs; better care; and zero cuts to Medicaid" – because the bill was (1) "almost certain" to reduce overall health care coverage and increase deductibles and (2) would phase out the Medicaid expansion. Among the key concerns identified by health-care experts were that (1) the tax credits funded at the level proposed in the bill are insufficient to pay for individual insurance, and could lead to Americans dropping out of the health care market; (2) the bill's elimination of the ACA's
community rating Community rating is a concept usually associated with health insurance, which requires health insurance providers to offer health insurance policies within a given territory at the same price to all persons without medical underwriting, regardless ...
provision (barring insurance companies from charging older people more than three times what they charge younger people) would increase cost disparities between age groups and would increase premiums for Americans more prone to illness; (3) the dropping of healthy people from the health insurance market (
adverse selection In economics, insurance, and risk management, adverse selection is a market situation where buyers and sellers have different information. The result is that participants with key information might participate selectively in trades at the expe ...
) could lead to insurer "death spirals" that would decrease choice; and (4) the phaseout of the Medicaid expansion was likely to result in a loss of healthcare for poorer Americans.


Estimated impact of the Republican AHCA and BCRA

The nonpartisan
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. Ins ...
has evaluated ("scored") the AHCA (initial and revised) and BCRA with respect to health insurance coverage, impact on the annual budget deficit, cost of insurance, and quality of insurance (i.e., the actuarial value, or percent of costs a given policy is expected to cover). Other groups have evaluated some of these elements, as well as the distributional impact of the tax changes by income level and impact on job creation. The results of these analyses are as follows:


Health insurance coverage

According to each of the CBO scores, passage of the Republican bills would result in a dramatic reduction in the number of persons with health insurance, relative to current law. *Persons with healthcare insurance coverage would be reduced by 14 million in 2018, 21 million in 2020, and 24 million in 2026 relative to current law. *In 2018, most of the reduction would be caused by the elimination of the penalties for the individual mandate, both directly and indirectly. Later reductions would be due to reductions in Medicaid enrollment, elimination of the individual mandate penalty, subsidy reduction, and higher costs for some persons. *By 2026, an estimated 49 million people would be uninsured under the Senate BCRA, versus 28 million under current law.


Non-CBO coverage estimates

* According to a report viewed by ''
Politico ''Politico'' (stylized in all caps), known originally as ''The Politico'', is an American, German-owned political journalism newspaper company based in Arlington County, Virginia, that covers politics and policy in the United States and intern ...
'', the White House
Office of Management and Budget The Office of Management and Budget (OMB) is the largest office within the Executive Office of the President of the United States (EOP). OMB's most prominent function is to produce the president's budget, but it also examines agency programs, pol ...
's own analysis of the AHCA estimated that 26 million people would under AHCA lose coverage over the next decade. According to White House Communications Director Michael Dubke, the analysis tried to use similar methodology as the CBO. *Other individuals and organizations such as the
Brookings Institution The Brookings Institution, often stylized as simply Brookings, is an American research group founded in 1916. Located on Think Tank Row in Washington, D.C., the organization conducts research and education in the social sciences, primarily in e ...
and S&P estimated sizable coverage losses due to the AHCA.

* According to a report published by the
Center on Budget and Policy Priorities The Center on Budget and Policy Priorities (CBPP) is a progressive American think tank that analyzes the impact of federal and state government budget policies. A 501(c)(3) nonprofit organization, the Center's stated mission is to "conduct resear ...
, the legislation would lead to 3 million more children (defined as persons under 18 years old) losing healthcare coverage.


Budget deficit

CBO has evaluated the impact on the budget deficit in each of its scores, generally finding a moderate reduction relative to current law: *CBO AHCA March 13: The AHCA would reduce the deficit relative to current law by $337 billion over a decade. Approximately $1.2 trillion less would be spent over that time, while $900 billion less in tax revenue would be collected. Medicaid spending would be cut considerably. Taxes on the roughly top 5% of income-earners under current law would considerably drop. *CBO AHCA Revised March 24: In negotiations after the initial report, the law was modified such that the CBO estimated the deficit reduction would total about $150 billion over a decade. *CBO BCRA June 26: A reduction of $321 billion over a decade. For scale, CBO has estimated that the U.S. will add approximately $9.4 trillion to the debt total over the 2018-2027 period, based on laws in place as of January 2017. The $321 billion therefore represents a reduction of about 3.5% of the total debt increase over the decade, while the $150 billion is about 1.6%.


Insurance costs and quality

There are many variables that affect premiums, deductibles, and out-of-pocket amounts, including (among others) age and health of plan participants, availability of subsidies, funding for high-risk pools, required insurance coverage elements, lifetime limits, maximum ratio of prices charged to older persons versus younger, and the quality of insurance offered. Regarding quality, the "actuarial value" is an estimate of the percentage of total cost that a particular insurance plan is expected to cover. CBO reported that: * CBO AHCA March 13: Insurance premiums would rise initially relative to current law, but would be reduced in the future moderately: "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 (which CBO and JCT expect to largely be used by states to limit the costs to insurers of enrollees with very high claims); 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. By 2026, average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than under current law..." * CBO AHCA March 13: Premium changes would vary significantly by age: "Under the legislation, insurers would be allowed to generally charge five times more for older enrollees than younger ones rather than three times more as under current law, substantially reducing premiums for young adults and substantially raising premiums for older people." This would lead to a mix of younger enrollees, one of the reasons for the lower overall premiums over the longer-term. *CBO BCRA June 26: "In 2020, average premiums for benchmark plans for single individuals would be about 30 percent lower than under current law. A combination of factors would lead to that decrease—most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums. That share of services covered by insurance would be smaller because the benchmark plan under this legislation would have an actuarial value of 58 percent beginning in 2020. That value is slightly below the actuarial value of 60 percent for "bronze" plans currently offered in the marketplaces." *CBO BCRA June 26: "Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income—also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan..." *CBO BCRA June 26: CBO has provided a summary (table #5 on page 48) that compares premiums under current law (ACA) with the BCRA, for different ages and income levels, for bronze and silver plans. For example, a single individual 40 years old with annual income of $56,800 (375% of poverty level) would pay $5,000 for a bronze plan under BCRA vs. $5,500 under current law, but receives a lower actuarial value plan of 58 versus 60. For that person, silver plans would be basically identical in terms of cost and quality. Relative to current law, persons aged 64 years old would pay considerably more for either a bronze or silver plan under BCRA, while a 21 year old would pay considerably less under BCRA, due in part to relaxing the rules on how much more older persons can be charged relative to younger.


Non-CBO cost estimates

*The Chief Actuary of
Centers for Medicare and Medicaid Services The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer M ...
of the
Department of Health and Human Services The United States Department of Health and Human Services (HHS) is a cabinet-level executive branch department of the U.S. federal government created to protect the health of all Americans and providing essential human services. Its motto is ...
released a report on June 13, 2017 providing their estimates of the legislation's impact. They estimated that gross premiums would decrease by 13%, but net premiums, the amount paid by consumers after federal subsidies, would increase by 5% by 2026.


Taxation and income inequality

The current law (ACA) established two taxes on high-income individuals (defined as income over $200,000 for individuals or $250,000 for couples, roughly the top 6% of earners), via a 0.9% Medicare payroll surtax on earnings over that threshold and a 3.8% tax on net investment income. The latter tax is steeply progressive, with the top 1% paying 90% of the tax, as investment income is highly concentrated with the wealthy. The ACA also established a penalty tax (related to the individual mandate) for individuals without adequate insurance, an excise tax on employers with 50 or more workers who offer insufficient coverage, annual fees on health insurance providers, and the "Cadillac tax" (yet to be implemented as of 2017) on generous employer-sponsored health plans. Combined with subsidies that primarily benefit low-income households, the law significantly reduced income inequality after taxes and transfers. The Republican bills (AHCA and BCRA) essentially repeal all of the taxes, penalties and fees and postpone the "Cadillac tax" further. The
Tax Policy Center The Urban-Brookings Tax Policy Center, typically shortened to the Tax Policy Center (TPC), is a nonpartisan think tank based in Washington D.C. A joint venture of the Urban Institute and the Brookings Institution, it aims to provide independent ...
estimated in March 2017 that the AHCA would significantly reduce taxes for the wealthy, with those IRS tax units (an approximation for families) earning over $200,000 per year (the top 6%) receiving 70.6% of the benefit or a reduction of $5,680 in annual taxes on average. Those with incomes over $1 million (the top 0.4%) would see a tax decrease of $51,410 on average, receiving 46% of the benefit. In general, those with incomes over $50,000 would see a tax cut, while those with income below $50,000 would see a tax increase. Those with income below $10,000 would see a tax cut as well, but this benefit would be offset overall by reductions in Medicaid availability. The effects overall would worsen
income inequality There are wide varieties of economic inequality, most notably income inequality measured using the distribution of income (the amount of money people are paid) and wealth inequality measured using the distribution of wealth (the amount of we ...
. The
Center on Budget and Policy Priorities The Center on Budget and Policy Priorities (CBPP) is a progressive American think tank that analyzes the impact of federal and state government budget policies. A 501(c)(3) nonprofit organization, the Center's stated mission is to "conduct resear ...
(CBPP) reported that "The House bill would represent the largest transfer in modern U.S. history from low- and moderate-income people to the very wealthy." CBPP also wrote: "Millionaires would gain roughly $40 billion in tax cuts annually...roughly equivalent to the $38 billion that 32 million households in poverty would lose from cuts to their tax credits and Medicaid."


Medicaid

Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
is the U.S. program for low-income children, adults, seniors and people with disabilities, covering one in five Americans. It is the primary payer of nursing home care. The ACA (current law) expanded Medicaid eligibility; 31 states and the District of Columbia implemented the expansion. Approximately 41% of Medicaid enrollees are white, 25% are Hispanic, and 22% are black. The proportion of white recipients in key swing states are 67% in Ohio, 59% in Michigan, and 58% in Pennsylvania. About 48% of recipients are children (18 or under). Most of the cost savings (deficit reduction) under AHCA and BCRA is due to reductions in
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
spending and coverage relative to current law. CBO estimated that there would be 15 million fewer Medicaid enrollees relative to current law by 2026, the largest component of the reduced coverage discussed above. CBO estimated that Medicaid spending under BCRA would be 26% lower in 2026 and 35% lower in 2036 relative to current law. This would reduce Medicaid spending in 2036 from 2.4% GDP under current law to 1.6% GDP. The reductions are driven by reduced funding to states for those who became covered under the Medicaid expansion in the current law (ACA), reducing the inflation index used to compute per-enrollee payments to states, and eliminating coverage mandates. While the nominal spending amounts continue to rise but at a slower pace, adjusted for inflation the amounts are actually cut moderately relative to 2017 levels.


Jobs

According to researchers at the Milken Institute School of Public Health at
George Washington University , mottoeng = "God is Our Trust" , established = , type = Private federally chartered research university , academic_affiliations = , endowment = $2.8 billion (2022) , presi ...
, the AHCA legislation would lead to a loss of 924,000 jobs by 2026. The group also studied the BCRA, which would cost an estimated 1.45 million jobs by 2026, including over 900,000 in healthcare. The stimulus effects from tax cuts would initially create jobs, but would be offset by the larger declines in spending as the various parts of the law take effect. Further, gross state products would be $162 billion lower in 2026. States that expanded Medicaid would bear the brunt of the economic impact, as government funds would be reduced more significantly.


Exchange stability

Under both the ACA (current law) and the AHCA, CBO reported that the health exchange marketplaces would remain stable (i.e., no "death spiral").
Yale Law School Yale Law School (Yale Law or YLS) is the law school of Yale University, a private research university in New Haven, Connecticut. It was established in 1824 and has been ranked as the best law school in the United States by '' U.S. News & World ...
professor Abbe R. Gluck, the director of the Solomon Center for Health Law and Policy, writes that Republican elected officials have taken a variety of steps to "sabotage" the ACA, creating uncertainty that has likely adversely impacted enrollment and insurer participation, and then insisting that the exchanges are in difficulty as an argument for repealing the ACA. ''The Washington Post'' columnist
Dana Milbank Dana Timothy Milbank (born April 27, 1968) is an American author and columnist for ''The Washington Post''. Personal life Milbank was born to a Jewish family, the son of Ann C. and Mark A. Milbank. He is a graduate of Yale University, where he wa ...
has made the same argument. Health insurance writer Louise Norris states that Republicans sabotaged the ACA through: *Lawsuits, both successful (Medicaid expansion limited) and unsuccessful (mandates and insurance subsidies upheld). *Lawsuits pending, such as whether cost-sharing subsidies must be paid. President Trump is threatening not to pay these subsidies. *Prevention of appropriations for transitional financing ("risk corridors") to steady insurance markets, resulting in the bankruptcy of many co-ops offering insurance. *Weakening of the individual mandate through IRS-related executive orders to limit penalty collection. *Reduction to funding for advertising for the 2017 exchange enrollment period. *Ongoing insistence, despite CBO assertions to the contrary, that the exchanges are unstable or in a "death spiral".


Other impact

* Social Security expenditures would decrease due to earlier mortality: "CBO also estimates that outlays for Social Security benefits would decrease by about $3 billion over the 2017–2026 period." * Medicaid expenditures would increase due to reduced access to birth control. "By CBO's estimates, in the one-year period in which federal funds for Planned Parenthood would be prohibited under the legislation, the number of births in the Medicaid program would increase by several thousand, increasing direct spending for Medicaid by $21 million in 2017 and by $77 million over the 2017–2026 period." * Two reports from the
Center for Budget and Policy Priorities The Center on Budget and Policy Priorities (CBPP) is a progressive American think tank that analyzes the impact of federal and state government budget policies. A 501(c)(3) nonprofit organization, the Center's stated mission is to "conduct resear ...
concluded that the ACHA would have shifted $370 billion in Medicaid costs to the states, which would have then been forced to cut coverage and services, and would make health insurance far less affordable in high-cost states, particularly 11 states in which tax credit would have been more the halved. * Every year one in 830 uninsured Americans die in a way which could have been prevented with better health care. A
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. Ins ...
report suggests an extra 16 million people would be left uninsured leading to 19,277 preventable deaths. Other uninsured people would develop painful chronic conditions or permanent disabilities which could have been prevented with health insurance.


Other provisions

The bills would allow states to continue to enroll persons in the ACA
Medicaid expansion In the context of American public healthcare policy, Medicaid coverage gap refers to uninsured people who reside in states which have opted out of Medicaid expansion under the Affordable Care Act (ACA), who are both ineligible for Medicaid unde ...
through January 1, 2020, and would disallow further enrollment after that date. The AHCA will include age-based tax credits for those who earn less than $75,000, or $150,000 for joint filers. The bill would have required insurance companies to cover pre-existing conditions. The AHCA used a standard of 'continuous coverage', defined by a 63-day coverage gap, where an individual who currently has insurance and is changing insurers will not pay a higher rate with their new insurer. Individuals who wished to buy insurance but were outside of the coverage gap would have paid a 30 percent premium surcharge for one year and then return to standard rates. Both healthy and the sick were required to pay the surcharge, which may have caused healthier persons to remain outside of the market, causing overall
health care costs Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World Health Organiz ...
to rise (see
adverse selection In economics, insurance, and risk management, adverse selection is a market situation where buyers and sellers have different information. The result is that participants with key information might participate selectively in trades at the expe ...
, high-risk pool).


Accuracy of CBO coverage forecasts

In general, CBO has been more accurate than other significant forecasting entities regarding the coverage impact of the ACA/Obamacare. It has been very accurate with respect to forecasting the number of uninsured and change in uninsured, but off significantly in forecasting the number of persons who would enroll in the exchanges. Instead, many more persons retained their employer-based plan than CBO had anticipated. CBO revises its forecasts for health insurance coverage due to current law (ACA/Obamacare) annually. *CBO forecast in February 2010 that there would be 31 million fewer uninsured in 2017 due to ACA; the 2016 forecast for 2017 was 24 million (7 million or 23% difference). The
Kaiser Family Foundation KFF (Kaiser Family Foundation), also known as The Henry J. Kaiser Family Foundation, is an American non-profit organization, headquartered in San Francisco, California. It prefers KFF since its legal name can cause confusion as it is no longer ...
estimated in October 2015 that 3.1 million additional people were not covered because of 19 states that rejected the Medicaid expansion in the wake of a 2012 Supreme Court decision that preserved their existing Medicaid funding whether or not they expanded coverage. This 2012 event accounts for much of the difference; CBO reduced its Medicaid coverage expansion forecast for the year 2017 by 5 million between 2010 and 2013. *CBO forecast in February 2013 that there would be 29 million uninsured in 2017; the 2017 forecast is 27 million (2 million or 7% difference). *CBO forecast in February 2013 that there would be 11 million additional persons covered by Medicaid in 2017; the 2017 forecast is 12 million (1 million or 9% difference). *CBO forecast in February 2013 that there would be 26 million additional persons covered under the exchanges in 2017; the 2017 forecast is 10 million (16 million or 62% difference). Regarding the inaccuracy of their exchange forecast, CBO explained that one of their assumptions was that more employers would choose to drop their coverage in favor of the exchanges than has actually occurred. CBO wrote in March 2017 that: "...most of the people who are no longer projected to obtain insurance through the marketplaces will instead be covered by employment-based insurance."


History


Initial version

The two bills that constituted the AHCA were introduced into the
House Energy and Commerce Committee The Committee on Energy and Commerce is one of the oldest standing committees of the United States House of Representatives. Established in 1795, it has operated continuously—with various name changes and jurisdictional changes—for more tha ...
and the
House Ways and Means Committee The Committee on Ways and Means is the chief tax-writing committee of the United States House of Representatives. The committee has jurisdiction over all taxation, tariffs, and other revenue-raising measures, as well as a number of other progra ...
on March 8, 2017 and passed both committees the next day. Both committees approved the AHCA on a party-line vote without a CBO report, prompting criticism from Democrats. House Minority Leader
Nancy Pelosi Nancy Patricia Pelosi (; ; born March 26, 1940) is an American politician who has served as Speaker of the United States House of Representatives since 2019 and previously from 2007 to 2011. She has represented in the United States House of ...
argued that the bill should not proceed through Congress until the CBO completed its analysis of the bill. Representative
Richard Neal Richard Edmund Neal (born February 14, 1949) is an American politician serving as the U.S. representative for since 1989. The district, numbered as the 2nd district from 1989 to 2013, includes Springfield, West Springfield, Pittsfield, H ...
, the ranking Democratic member of the House Ways and Means Committee, stated: "To consider a bill of this magnitude without a CBO score is not only puzzling and concerning, but also irresponsible." Trump administration officials, including budget director
Mick Mulvaney John Michael Mulvaney (born July 21, 1967) is an American politician who served as director of the Office of Management and Budget (OMB) from February 2017 until March 2020, and as acting White House Chief of Staff from January 2019 until March ...
and economic adviser
Gary Cohn Gary David Cohn (born August 27, 1960) is an American business leader who served as the 11th Director of the National Economic Council and chief economic advisor to President Donald Trump from 2017 to 2018. He managed the administration's econo ...
, preemptively attacked the CBO, with Cohn saying that the CBO's score would be "meaningless". These criticisms from the White House are unusual: prior administrations of both parties had refrained from questioning the CBO's credibility, and many members of Congress respect the CBO as a neutral body. The bill next went to the
House Budget Committee The United States House Committee on the Budget, commonly known as the House Budget Committee, is a standing committee of the United States House of Representatives. Its responsibilities include legislative oversight of the federal budget process, ...
, which passed it on March 16 by 19 to 17 votes, with three Republicans from the conservative
Freedom Caucus The Freedom Caucus, also known as the House Freedom Caucus, is a congressional caucus consisting of conservative Republican members of the United States House of Representatives. It is generally considered to be the most conservative and far ...
joining Democrats in opposition. It next went to the Rules Committee, which sets the terms of the debate before a bill comes to the full House. A House vote was initially scheduled for March 23, but was delayed for at least a day after Republican leaders were unable to find enough votes for passage. On March 24, with both moderate and far-right Republican lawmakers opposing the bill, Speaker Ryan and President Trump chose to withdraw the bill from consideration rather than go through with a full House vote that would have failed. The comparatively "lightning fast" legislative movement for the AHCA through the House was in contrast to the Affordable Care Act, which took months of negotiations, committee markup, and debate before passage in 2010. The quick process prompted complaints from Democrats "that the Republicans were rushing to approve a repeal bill without hearing from consumers, health care providers, insurance companies or state officials – and without having estimates of the cost or the impact on coverage from the Congressional Budget Office". In House committees, Democratic representatives offered more than 100 amendments to the legislation, including amendments that "would have required the law to guarantee no one would lose insurance, hospitals would not see an increase in uncompensated care, the deficit would not increase, taxes would not go up on people making less than $250,000, and that people over 55 years old would not lose benefits or pay higher out-of-pocket costs."Maureen Groppe
Democrats attempt to put brakes on Republican health care bill
, ''USA Today'' (March 8, 2017).
Democratic Representative
Joe Crowley Joseph Crowley (born March 16, 1962) is an American politician and consultant who served as U.S. Representative from New York's 14th congressional district from 1999 to 2019. He was defeated by Democratic primary challenger Alexandria Ocasio-C ...
of New York offered an amendment that during the 2010 Affordable Care Act debate had been proposed by Republican Representative
Kevin Brady Kevin Patrick Brady (born April 11, 1955) is an American politician and the U.S. representative for , serving since 1997. He is a member of the Republican Party. The district includes northern Houston, including The Woodlands. On April 14, 202 ...
of Texas, requiring "that the bill be posted online for 72 hours before any votes were taken on it, and that every member put a statement in the
Congressional Record The ''Congressional Record'' is the official record of the proceedings and debates of the United States Congress, published by the United States Government Publishing Office and issued when Congress is in session. The Congressional Record Inde ...
stating he or she had read the bill." All of these Democratic amendments were rejected, as Brady (the chairman of the
House Ways and Means Committee The Committee on Ways and Means is the chief tax-writing committee of the United States House of Representatives. The committee has jurisdiction over all taxation, tariffs, and other revenue-raising measures, as well as a number of other progra ...
) ruled that the amendments were "not germane" to the bill, and the Republican majority repeatedly upheld these rulings.


Division among House Republicans

In the days leading up to the vote, which was originally scheduled for March 23, 2017, there was increased division among House Republicans over the replacement, causing concerns among Republican Party leadership over having the votes needed to pass the bill. Among Republican defectors from the bill, the largest opposition came from members of the
House Freedom Caucus A house is a single-unit residential building. It may range in complexity from a rudimentary hut to a complex structure of wood, masonry, concrete or other material, outfitted with plumbing, electrical, and heating, ventilation, and air cond ...
, which consists of some of the most conservative members in the House. The Freedom Caucus members, among their primary objections to the bill, were not convinced that the healthcare replacement effectively abolished some elements of the Affordable Care Act, most prominently the
essential health benefits In the United States, essential health benefits (EHBs) are a set of ten benefits, defined under the Affordable Care Act (ACA) of 2010, that must be covered by individually-purchased health insurance and plans in small-group markets both inside and ...
. To achieve success in the House, Republicans could not afford more than twenty-one members of their own party voting against the bill, and several days before the vote, dissent within the party, largely from the Freedom Caucus, was a significant threat to its passage. Beyond the conservative members of the Freedom Caucus, there was continued opposition to the bill from more moderate Republicans in the House, such as from members of the
center-right Centre-right politics lean to the right of the political spectrum, but are closer to the centre. From the 1780s to the 1880s, there was a shift in the Western world of social class structure and the economy, moving away from the nobility and mer ...
Tuesday Group The Republican Governance Group, originally the Tuesday Lunch Bunch and then the Tuesday Group until 2020, is a group of moderate Republicans in the United States House of Representatives. It was founded in 1994 in the wake of the Republican tak ...
, where there were concerns about loss of coverage and the potential of rising insurance costs. Amid the division between the Republicans, the party leadership, which was led by House Speaker
Paul Ryan Paul Davis Ryan (born January 29, 1970) is an American former politician who served as the 54th speaker of the United States House of Representatives from 2015 to 2019. A member of the Republican Party, he was the vice presidential nominee i ...
, attempted to ease concerns among the Freedom Caucus and others. President Trump also held numerous meetings with Republicans in the House leading up to the vote, though after negotiations with the Freedom Caucus over the ACA's essential health benefits, there was still a considerable amount of opposition from moderates and members of the Freedom Caucus alike. On the day of the scheduled vote, which coincided with the seven-year anniversary of the ACA's signing into law, party leadership continued to struggle with getting the required votes for the bill, and the vote was rescheduled for the following day, March 24, 2017, as requested by the White House.


Withdrawal ahead of vote

The night before the rescheduled vote, Trump, in a final effort to negotiate with those opposing the bill, announced to the House Republicans that the vote the following day would be their only chance to repeal the Affordable Care Act, a goal long sought after by Republicans in Congress. The following morning the bill was brought to the House floor after being approved by the
House Rules Committee The Committee on Rules, or more commonly, the Rules Committee, is a committee of the United States House of Representatives. It is responsible for the rules under which bills will be presented to the House of Representatives, unlike other commit ...
for four hours of debate preceding the vote, which was expected in the afternoon. It was reported that a couple hours before the expected vote, Ryan made a sudden visit to the White House to meet with Trump, in which Ryan told Trump that the bill did not have enough votes to pass in the House. Shortly after the time of the expected vote it was announced that the Republicans were withdrawing the AHCA from consideration, a decision made after Ryan met with Trump. Following the withdrawal, Ryan stated in a press conference that the country is "going to be living with Obamacare for the foreseeable future", while Trump said that it was tough to pass the bill without support from Democrats; Ryan and Trump both said they were going to move forward on other policy issues.


Revised version

Through the various iterations of bill it has been nicknamed variously as Trumpcare, Ryancare, Republicare, and pejoratively as Obamacare-Lite, and Wealthcare.


MacArthur Amendment

In April 2017, House Republicans tried to reconcile their divisions with the proposed MacArthur Amendment. The MacArthur Amendment, developed by Representative
Tom MacArthur Thomas Charles MacArthur (born October 16, 1960) is an American former insurance executive and politician. He served as the U.S. representative for from 2015 to 2019. A Republican, MacArthur served on the city council of Randolph, New Jersey, ...
of the
Tuesday Group The Republican Governance Group, originally the Tuesday Lunch Bunch and then the Tuesday Group until 2020, is a group of moderate Republicans in the United States House of Representatives. It was founded in 1994 in the wake of the Republican tak ...
(representing more moderate Republicans) and Representative
Mark Meadows Mark Randall Meadows (born July 28, 1959) is an American politician who served as the 29th White House chief of staff from 2020 to 2021. A member of the Republican Party, he also served as the U.S. representative for North Carolina's 11th c ...
of the
House Freedom Caucus A house is a single-unit residential building. It may range in complexity from a rudimentary hut to a complex structure of wood, masonry, concrete or other material, outfitted with plumbing, electrical, and heating, ventilation, and air cond ...
(representing the hard-line right). The language of the proposed amendment became available on April 25, 2017. The amendment allows insurers to charge enrollees in their 50s and early 60s more than younger enrollees. It also allows states to waive essential health benefits and certain sections of the community rating program. As revised by the MacArthur Amendment, the ACHA weakens protections for patients with preexisting conditions; under this version of the bill, insurers would be able to charge people significantly more if they had a pre-existing condition.


Passage in House

On May 3, House Republicans announced that they had enough votes to pass the bill, after amending it to include an additional $8 billion over five years to subsidize insurance for people with pre-existing conditions. On May 4, 2017, the House of Representatives voted in favor of repealing the Patient Protection and Affordable Care Act and passing the American Health Care Act with a narrow vote of 217 to 213. Upon the bill's passing, congressional Republicans rushed to the White House for a televised celebration. 217 Republican Congressmen voted for the bill, while all 193 Democrats and 20 Republicans voted against it. Most of the Republicans who voted against the bill are members of the centrist Tuesday Group, and only one member of the Freedom Caucus voted against the bill.


Senate bills

The Senate developed several amendments / bills to modify the AHCA bill that had passed in the House, but none had received enough votes in the Senate to pass as of July 28, 2017. These included the: *Better Care Reconciliation Act of 2017 (BCRA), which was not voted on in its initial form, but as modified based on changes led by Senator Ted Cruz, was defeated in a 43–57 vote. *Obamacare Repeal Reconciliation Act of 2017 (ORRA), which would have essentially repealed Obamacare, and was defeated in a 45–55 vote. *Health Care Freedom Act of 2017 (HCFA) or "skinny repeal", which would have repealed the individual mandate but not the Medicaid expansion, and was defeated in a 49–51 vote. Under the various Senate bills, the CBO estimated that relative to current law, millions more would be without health insurance and the budget deficit would be reduced moderately (roughly 5% or less over a decade). The effect on insurance premiums would vary widely in the exchange marketplaces (the non-employer market created by Obamacare) depending on the specific legislation.


Better Care Reconciliation Act of 2017 (BCRA)

In the Senate, Majority Leader
Mitch McConnell Addison Mitchell McConnell III (born February 20, 1942) is an American politician and retired attorney serving as the senior United States senator from Kentucky and the Senate minority leader since 2021. Currently in his seventh term, McCon ...
appointed a group of 13 Republican Senators to prepare a bill. Democrats, independents, and other Republicans were excluded from the process and given no information until the new bill was released on June 22, 2017. The Senate bill is called the Better Care Reconciliation Act of 2017. The bill's differences from the House bill reflected divergent opinions within the Republican caucus. The phase-out of the Medicaid expansion would be made more gradual, but funding for Medicaid as it stood before the ACA would be reduced. Eligibility for premium subsidies would be tightened for middle-class recipients, but some aid would be extended to enrollees below the poverty level in states that did not expand Medicaid. The AHCA would have replaced the individual mandate with a provision that would allow an insurer to add a 30 percent surcharge to the premium if an individual goes without coverage for 63 days or more. The original draft of the BCRA would have repealed the ACA's individual mandate but it did not include the AHCA's continuous coverage provision. A few days after the draft's release, it was amended to provide that someone who went without coverage for 63 days or more would have to wait six months to obtain new coverage.


Obamacare Repeal Reconciliation Act of 2017 (ORRA)

The CBO evaluated the bill, concluding that relative to current law it would reduce the budget deficit by $473 billion over 10 years (roughly 5%), increase the number of uninsured by 17 million in 2018 and 27 million in 2020, and increase average premiums in the marketplaces (non-group/non-employer-based) by roughly 25% in 2018 and by 50% in 2020. Roughly half the U.S. population would live in areas with no insurers participating in the marketplaces.


Health Care Freedom Act of 2017 (HCFA)

On July 14, Senator
John McCain John Sidney McCain III (August 29, 1936 – August 25, 2018) was an American politician and United States Navy officer who served as a United States senator from Arizona from 1987 until his death in 2018. He previously served two te ...
had surgery to remove a
blood clot A thrombus (plural thrombi), colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of cr ...
. The next day, McConnell announced that the vote on proceeding to consider the bill would be deferred until McCain returned from his recuperation period. Senate Democrats urged the Republican leadership to "use this additional time to hold public hearings ... on the policies in the bill, especially the radically conservative Cruz/Lee proposal released to the public only five days ago." On July 17, Senators
Mike Lee Michael Shumway Lee (born June 4, 1971) is an American lawyer and politician serving as the senior United States senator from Utah, a seat he has held since 2011. He is a member of the Republican Party. Lee began his career as a clerk for the U ...
(R-UT) and
Jerry Moran Gerald Wesley Moran ( ; born May 29, 1954) is an American lawyer and politician who is the senior United States senator from Kansas, a seat he has held since 2011. A member of the Republican Party, he was chair of the National Republican Senator ...
(R-KS) came out against the bill, joining
Rand Paul Randal Howard Paul (born January 7, 1963) is an American physician and politician serving as the Seniority in the United States Senate, junior United States Senate, U.S. senator from Kentucky since 2011. A member of the Republican Party (Un ...
and
Susan Collins Susan Margaret Collins (born December 7, 1952) is an American politician serving as the senior United States senator from Maine. A member of the Republican Party, she has held her seat since 1997 and is Maine's longest-serving member of Con ...
who already opposed it, making it impossible for Republicans alone to pass it through. It was later revealed that John McCain was diagnosed with
brain cancer A brain tumor occurs when abnormal cells form within the brain. There are two main types of tumors: malignant tumors and benign (non-cancerous) tumors. These can be further classified as primary tumors, which start within the brain, and second ...
, which was discovered during his surgery. On July 25, Senate Republicans released a significantly stripped-down version of the healthcare bill, containing only fundamental provisions of the repeal that all Republicans agreed on, designed to only pass the motion to proceed to floor debate, still allowing further amendments to be added on the floor before final passage. The motion to proceed on this version of the bill passed in a 51–50 vote, with a tie-breaking vote cast by Vice President Mike Pence; Senators
Susan Collins Susan Margaret Collins (born December 7, 1952) is an American politician serving as the senior United States senator from Maine. A member of the Republican Party, she has held her seat since 1997 and is Maine's longest-serving member of Con ...
and
Lisa Murkowski Lisa Ann Murkowski ( ; born May 22, 1957) is an American attorney and politician serving as the senior United States senator for Alaska, having held that seat since 2002. Murkowski is the second-most senior Republican woman in the Senate, after S ...
diverged from their party and voted against the measure. Senator John McCain traveled to Washington for the vote, returning to Senate for the first time since his cancer diagnosis. After several failed votes within 24 hours of the bill being passed to floor debate, including a repeal without replace bill, the Republican senate leadership attempted to pass the Health Care Freedom Act (HCFA), referred to as a "skinny repeal." The skinny repeal, which was still being drafted on July 27, only repeals some provisions of the ACA, among them the
individual mandate An individual mandate is a requirement by law for certain persons to purchase or otherwise obtain a good or service. United States Militia act The Militia Acts of 1792, based on the Constitution's militia clause (in addition to its affirmativ ...
, requiring that all Americans buy insurance or pay a tax penalty, and parts of the
employer mandate A health insurance mandate is either an employer or individual mandate to obtain private health insurance instead of (or in addition to) a national health insurance plan.D. Andrew Austin, Thomas L. Hungerford (2010). Market Structure of the ...
, which requires employers with greater than 50 employees to pay for health care for their employees. The bill was brought to the floor vote and the vote reached the predicted 49–50, majority being in favor of keeping the ACA as is. A tie would have allowed
Vice President A vice president, also director in British English, is an officer in government or business who is below the president (chief executive officer) in rank. It can also refer to executive vice presidents, signifying that the vice president is on ...
Mike Pence Michael Richard Pence (born June 7, 1959) is an American politician who served as the 48th vice president of the United States from 2017 to 2021 under President Donald Trump. A member of the Republican Party, he previously served as the 50th ...
to cast a final tie breaking vote. The final vote was to be McCain, who walked to the floor in near silence and held out his hand. In a very climactic moment, he gave a thumbs down and the bill was rejected 49–51, with two other Republican senators,
Susan Collins Susan Margaret Collins (born December 7, 1952) is an American politician serving as the senior United States senator from Maine. A member of the Republican Party, she has held her seat since 1997 and is Maine's longest-serving member of Con ...
and
Lisa Murkowski Lisa Ann Murkowski ( ; born May 22, 1957) is an American attorney and politician serving as the senior United States senator for Alaska, having held that seat since 2002. Murkowski is the second-most senior Republican woman in the Senate, after S ...
, siding with all Democrats and Independents.


Graham-Cassidy

On September 13, 2017, Senators
Graham Graham and Graeme may refer to: People * Graham (given name), an English-language given name * Graham (surname), an English-language surname * Graeme (surname), an English-language surname * Graham (musician) (born 1979), Burmese singer * Clan ...
, Cassidy, Heller, and
Johnson Johnson is a surname of Anglo-Norman origin meaning "Son of John". It is the second most common in the United States and 154th most common in the world. As a common family name in Scotland, Johnson is occasionally a variation of ''Johnston'', a ...
released a draft amendment to the bill that "repeals the structure and architecture of Obamacare and replaces it with a block grant given annually to states". However, it was not voted upon due to lack of support. On October 12, 2017, due to this failure of Congress to pass a repeal, President
Donald Trump Donald John Trump (born June 14, 1946) is an American politician, media personality, and businessman who served as the 45th president of the United States from 2017 to 2021. Trump graduated from the Wharton School of the University of P ...
issued Executive Order 13813, titled an Executive Order to Promote Healthcare Choice and Competition.


Reaction


Initial version

President Trump endorsed the bill after its release, calling it "our wonderful new Healthcare Bill" on Twitter. Speaker of the House
Paul Ryan Paul Davis Ryan (born January 29, 1970) is an American former politician who served as the 54th speaker of the United States House of Representatives from 2015 to 2019. A member of the Republican Party, he was the vice presidential nominee i ...
referred to the bill as a "conservative wish list" that would provide for "monumental, exciting conservative reform". Economist
Douglas Holtz-Eakin Douglas James "Doug" Holtz-Eakin (born February 3, 1958) is an American economist. He was formerly an economics professor at Syracuse University, Director of the Congressional Budget Office, and chief economic policy adviser to Senator John McCain ...
described the AHCA as "a good start". But conservative members of the
Republican Party Republican Party is a name used by many political parties around the world, though the term most commonly refers to the United States' Republican Party. Republican Party may also refer to: Africa * Republican Party (Liberia) *Republican Party ...
quickly raised skepticism about the proposed reform as they would prefer a complete repeal of the PPACA. The
White House The White House is the official residence and workplace of the president of the United States. It is located at 1600 Pennsylvania Avenue NW in Washington, D.C., and has been the residence of every U.S. president since John Adams in ...
sent
Mick Mulvaney John Michael Mulvaney (born July 21, 1967) is an American politician who served as director of the Office of Management and Budget (OMB) from February 2017 until March 2020, and as acting White House Chief of Staff from January 2019 until March ...
, executive of the
Office of Management and Budget The Office of Management and Budget (OMB) is the largest office within the Executive Office of the President of the United States (EOP). OMB's most prominent function is to produce the president's budget, but it also examines agency programs, pol ...
, to convince members of the
House Freedom Caucus A house is a single-unit residential building. It may range in complexity from a rudimentary hut to a complex structure of wood, masonry, concrete or other material, outfitted with plumbing, electrical, and heating, ventilation, and air cond ...
to support the legislation. According to numerous reports, Mulvaney was unsuccessful. Shortly after the meeting caucus chairman
Mark Meadows Mark Randall Meadows (born July 28, 1959) is an American politician who served as the 29th White House chief of staff from 2020 to 2021. A member of the Republican Party, he also served as the U.S. representative for North Carolina's 11th c ...
said, "No new position tonight. Our position is the same. We believe we need to do a clean repeal bill." A number of conservative groups have also criticized the bill for not being enough of a repeal, calling it "Obamacare 2.0". The Koch brother-supported organizations Americans for Prosperity and Freedom Partners have indicated their intention to put together a multimillion-dollar fund in support of re-election campaigns for conservative lawmakers who take a stand against the bill. The
AARP AARP (formerly called the American Association of Retired Persons) is an interest group in the United States focusing on issues affecting those over the age of fifty. The organization said it had more than 38 million members in 2018. The magazi ...
released a statement opposing the bill. Stating, "On top of the hefty premium increase for consumers, big drug companies and other special interests get a sweetheart deal". The
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's sta ...
released a statement opposing the bill.
America's Essential Hospitals America's Essential Hospitals (formerly the National Association of Public Hospitals and Health Systems) is an industry trade group that represents more than 300 hospitals that fill a safety net role in their communities. The association, a nonprof ...
, American Hospital Association,
Association of American Medical Colleges The Association of American Medical Colleges (AAMC) is a nonprofit organization based in Washington, D.C. that was established in 1876. It represents medical school A medical school is a tertiary educational institution, or part of such an i ...
,
Catholic Health Association of the United States The Catholic Health Association of the United States (CHA), formerly the Catholic Hospital Association of the United States and Canada, is a Catholic professional association comprising more than 600 hospitals and 1,400 long-term care and other hea ...
,
Children's Hospital Association The Children's Hospital Association (CHA), is an organization of children's hospitals with more than 200 members in the United States, Australia, Canada, Italy, Mexico and Puerto Rico. CHA has offices located in Lenexa, Kansas Lenexa is a ...
,
Federation of American Hospitals The Federation of American Hospitals is a trade association for tax-paying hospitals in the United States. It is based in Washington D.C. As of 2009 it was headed by "Chip" Kahn. See also *List of industry trade groups in the United States *Heal ...
, and National Association of Psychiatric Health Systems also stated their opposition in a joint letter. Conservative groups, including
Heritage Action Heritage Action for America, more commonly known simply as Heritage Action, is a conservative policy advocacy organization founded in 2010. Heritage Action, which has affiliates throughout the United States, is a sister organization of the conser ...
, the
Cato Institute The Cato Institute is an American libertarian think tank headquartered in Washington, D.C. It was founded in 1977 by Ed Crane, Murray Rothbard, and Charles Koch, chairman of the board and chief executive officer of Koch Industries.Koch Ind ...
,
Americans for Prosperity Americans for Prosperity (AFP), founded in 2004, is a libertarian conservative political advocacy group in the United States funded by Charles Koch and formerly his brother David. As the Koch brothers' primary political advocacy group, it is one ...
,
FreedomWorks FreedomWorks is a conservative and libertarian advocacy group based in Washington, D.C. FreedomWorks trains volunteers, assists in campaigns, and encourages them to mobilize, interacting with both fellow citizens and their political representat ...
, and the Tea Party Patriots all oppose the bill. Progressive groups, including MoveOn.org, American Bridge, the
Center for American Progress The Center for American Progress (CAP) is a public policy research and advocacy organization which presents a liberal viewpoint on economic and social issues. It has its headquarters in Washington, D.C. The president and chief executive offic ...
, and
Our Revolution Our Revolution (sometimes known by its initials OR) is an American progressive political action organization spun out of Senator Bernie Sanders's 2016 presidential campaign to continue its work. The organization's mission is to educate voter ...
, were resolutely opposed to the bill, as expected. Economist and ''
The New York Times ''The New York Times'' (''the Times'', ''NYT'', or the Gray Lady) is a daily newspaper based in New York City with a worldwide readership reported in 2020 to comprise a declining 840,000 paid print subscribers, and a growing 6 million paid ...
'' columnist
Paul Krugman Paul Robin Krugman ( ; born February 28, 1953) is an American economist, who is Distinguished Professor of Economics at the Graduate Center of the City University of New York, and a columnist for ''The New York Times''. In 2008, Krugman was t ...
stated that the bill's "awfulness is almost surreal", writing that what Republican congressional leadership "came up with instead was a dog's breakfast that conservatives are, with some justice, calling Obamacare 2.0. But a better designation would be Obamacare 0.5, because it's a half-baked plan that accepts the logic and broad outline of the Affordable Care Act while catastrophically weakening key provisions." On March 23, 2017 (the seventh anniversary of ACA and one day prior to the vote on the American Health Care Act), former President Obama hailed the successes of the Affordable Care Act, including 20 million more Americans insured, preexisting conditions covered, young people staying on their parents' plans until 26, lowered costs for women's health care and free preventive care.


Later versions

After the House passed the AHCA, but before any legislation passed the Senate, Republican congressmen gathered with Trump to celebrate in the
Rose Garden A rose garden or rosarium is a garden or park, often open to the public, used to present and grow various types of garden roses, and sometimes rose species. Most often it is a section of a larger garden. Designs vary tremendously and roses m ...
. In his speech, Trump described the bill as "very incredibly well-crafted." Republican Senators expressed less enthusiasm about the bill and opted to draft their own bill instead of taking up the House's version. Congressional Democrats and interest groups, such as the
AARP AARP (formerly called the American Association of Retired Persons) is an interest group in the United States focusing on issues affecting those over the age of fifty. The organization said it had more than 38 million members in 2018. The magazi ...
,
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's sta ...
,
ACLU The American Civil Liberties Union (ACLU) is a nonprofit organization founded in 1920 "to defend and preserve the individual rights and liberties guaranteed to every person in this country by the Constitution and laws of the United States". ...
, and
Planned Parenthood The Planned Parenthood Federation of America, Inc. (PPFA), or simply Planned Parenthood, is a nonprofit organization that provides reproductive health care in the United States and globally. It is a tax-exempt corporation under Internal Reve ...
, expressed their opposition to the bill. At a lunch with Senate Republicans in June 2017, Trump reportedly called the AHCA "mean, mean, mean" and a "son of a bitch". He reportedly implored the Senators to make their version of the bill "more generous, more kind." Later that month, Trump confirmed that he had used the term "mean" to describe the bill. On June 16, 2017, a
bipartisan Bipartisanship, sometimes referred to as nonpartisanship, is a political situation, usually in the context of a two-party system (especially those of the United States and some other western countries), in which opposing political parties find co ...
group of seven current Governors sent a letter to Senate Majority and Minority Leaders
Mitch McConnell Addison Mitchell McConnell III (born February 20, 1942) is an American politician and retired attorney serving as the senior United States senator from Kentucky and the Senate minority leader since 2021. Currently in his seventh term, McCon ...
and
Chuck Schumer Charles Ellis Schumer ( ; born November 23, 1950) is an American politician serving as Senate Majority Leader since January 20, 2021. A member of the Democratic Party, Schumer is in his fourth Senate term, having held his seat since 1999, an ...
criticizing the House's legislation and requesting a bipartisan effort in the Senate to reform healthcare. The signatories include Governors
John Kasich John Richard Kasich Jr. ( ; born May 13, 1952) is an American politician, author, and television news host who served in the U.S. House of Representatives from 1983 to 2001 and as the 69th governor of Ohio from 2011 to 2019. A Republican, Kasic ...
(
Ohio Ohio () is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. Of the List of states and territories of the United States, fifty U.S. states, it is the List of U.S. states and territories by area, 34th-l ...
),
Steve Bullock Steve, Steven, or Stephen Bullock may refer to: *Steve Bullock (British politician) (born 1953), first directly elected mayor of the London Borough of Lewisham *Steve Bullock (American politician) Stephen Clark Bullock (born April 11, 1966) is ...
(
Montana Montana () is a state in the Mountain West division of the Western United States. It is bordered by Idaho to the west, North Dakota and South Dakota to the east, Wyoming to the south, and the Canadian provinces of Alberta, British Columb ...
),
Brian Sandoval Brian Edward Sandoval (; born August 5, 1963) is an American politician, academic administrator, and former federal judge who served as the 29th Governor of Nevada from 2011 to 2019. A graduate of the University of Nevada, Reno, Sandoval began ...
 (
Nevada Nevada ( ; ) is a U.S. state, state in the Western United States, Western region of the United States. It is bordered by Oregon to the northwest, Idaho to the northeast, California to the west, Arizona to the southeast, and Utah to the east. N ...
),
John Bel Edwards John Bel Edwards (born September 16, 1966) is an American politician and attorney serving as the 56th governor of Louisiana since 2016. A member of the Democratic Party, he previously served as the Democratic leader of the Louisiana House of ...
 (
Louisiana Louisiana , group=pronunciation (French: ''La Louisiane'') is a state in the Deep South and South Central regions of the United States. It is the 20th-smallest by area and the 25th most populous of the 50 U.S. states. Louisiana is bord ...
),
John Hickenlooper John Wright Hickenlooper Jr. (; born February 7, 1952) is an American politician serving as the junior United States senator from Colorado since 2021. A member of the Democratic Party, he served as the 42nd governor of Colorado from 2011 to 20 ...
 (
Colorado Colorado (, other variants) is a state in the Mountain West subregion of the Western United States. It encompasses most of the Southern Rocky Mountains, as well as the northeastern portion of the Colorado Plateau and the western edge of the ...
),
Charlie Baker Charles Duane Baker Jr. (born November 13, 1956) is an American politician and businessman serving as the 72nd governor of Massachusetts since 2015. A member of the Republican Party, Baker was a cabinet official under two governors of Massach ...
 (
Massachusetts Massachusetts (Massachusett: ''Muhsachuweesut Massachusett_writing_systems.html" ;"title="nowiki/> məhswatʃəwiːsət.html" ;"title="Massachusett writing systems">məhswatʃəwiːsət">Massachusett writing systems">məhswatʃəwiːsət'' En ...
), and
Tom Wolf Thomas Westerman Wolf (born November 17, 1948) is an American politician and businessman serving as the 47th governor of Pennsylvania since 2015. A member of the Democratic Party, he defeated Republican incumbent Tom Corbett in the 2014 gu ...
(
Pennsylvania Pennsylvania (; ( Pennsylvania Dutch: )), officially the Commonwealth of Pennsylvania, is a state spanning the Mid-Atlantic, Northeastern, Appalachian, and Great Lakes regions of the United States. It borders Delaware to its southeast, ...
). When the Senate bill text (BCRA) was released, four conservative Republican Senators –
Ted Cruz Rafael Edward "Ted" Cruz (; born December 22, 1970) is an American politician and attorney serving as the junior United States Senator from Texas since 2013. A member of the Republican Party, Cruz served as Solicitor General of Texas fro ...
, Ron Johnson,
Mike Lee Michael Shumway Lee (born June 4, 1971) is an American lawyer and politician serving as the senior United States senator from Utah, a seat he has held since 2011. He is a member of the Republican Party. Lee began his career as a clerk for the U ...
, and
Rand Paul Randal Howard Paul (born January 7, 1963) is an American physician and politician serving as the Seniority in the United States Senate, junior United States Senate, U.S. senator from Kentucky since 2011. A member of the Republican Party (Un ...
 – released a joint statement saying that they would not vote for the bill in that form. This was seen as an attempt to move the bill to the right by bringing pressure on McConnell. The next day, Senator
Dean Heller Dean Arthur Heller (born May 10, 1960) is an American businessman and politician who served as a United States senator for Nevada from 2011 to 2019. A member of the Republican Party, he served as the 15th secretary of state of Nevada from 1995 ...
of
Nevada Nevada ( ; ) is a U.S. state, state in the Western United States, Western region of the United States. It is bordered by Oregon to the northwest, Idaho to the northeast, California to the west, Arizona to the southeast, and Utah to the east. N ...
announced his opposition. He emphasized the effect on Medicaid, noting that the bill's cuts to Medicaid would "pull the rug" out from under many Nevada residents.


Public opinion

An analysis of national polls by
MIT The Massachusetts Institute of Technology (MIT) is a private land-grant research university in Cambridge, Massachusetts. Established in 1861, MIT has played a key role in the development of modern technology and science, and is one of the m ...
political scientist Christopher Warshaw and
Stanford Stanford University, officially Leland Stanford Junior University, is a Private university, private research university in Stanford, California. The campus occupies , among the largest in the United States, and enrolls over 17,000 students. S ...
political economist David Broockman showed that the AHCA "is the most unpopular piece of major legislation Congress has considered in decades" more so than Troubled Asset Relief Program legislation ("the bank bailout") and much more unpopular than the ACA. Their estimates of survey results indicate that there is not majority support for the bill in any state. Public opinion polls show high levels of public opposition to the Republican health-care proposals (the AHCA in the House and the BCRA in the Senate). Approval ratings vary between 12 and 38%, and disapproval ratings between 41% and 62%, measured between March and June 2017 (refer to "Specific poll results" table below for sources). Views were split along party lines. For example, the monthly
Kaiser Family Foundation KFF (Kaiser Family Foundation), also known as The Henry J. Kaiser Family Foundation, is an American non-profit organization, headquartered in San Francisco, California. It prefers KFF since its legal name can cause confusion as it is no longer ...
health tracking poll for May 2017 indicated that: * More view the Republican AHCA unfavorably (55%) than favorably (31%). * Views are split along party lines, with % in favor of AHCA: Democrats 8%, Independents 30%, Republicans 67%. * Although historically more people viewed the current law (ACA/"Obamacare") unfavorably than favorably, in May 2017 more had a favorable view (49%) than unfavorable (42%). * More favorably view the ACA/Obamacare (49%) than the Republican AHCA (31%).


Specific poll results

The following are the results of polls of public opinion regarding the AHCA.


2018 elections

The
Niskanen Center The Niskanen Center is a Washington, D.C.-based think tank that advocates environmentalism, immigration reform, civil liberties, and strengthening social insurance around market-oriented principles. The center is named after William A. Niskane ...
stated that the GOP's support for AHCA in 2017 was a major factor in the party's heavy House losses in the 2018 midterm elections, costing the party its majority in the House, and
Snopes ''Snopes'' , formerly known as the ''Urban Legends Reference Pages'', is a fact-checking website. It has been described as a "well-regarded reference for sorting out myths and rumors" on the Internet. The site has also been seen as a source f ...
publicly identified 33 House Republicans who were voted out of office largely due to their votes in favor of the AHCA, including in states where Republicans control most House seats, such as
Kansas Kansas () is a U.S. state, state in the Midwestern United States, Midwestern United States. Its Capital city, capital is Topeka, Kansas, Topeka, and its largest city is Wichita, Kansas, Wichita. Kansas is a landlocked state bordered by Nebras ...
and
Utah Utah ( , ) is a state in the Mountain West subregion of the Western United States. Utah is a landlocked U.S. state bordered to its east by Colorado, to its northeast by Wyoming, to its north by Idaho, to its south by Arizona, and to its ...
.


Comparison between versions

This table describes major differences and similarities between the ACA, the AHCA as considered in the House in March 2017, the AHCA as passed by the House on May 4, 2017, and the BCRA.

The Kaiser Family Foundation has also summarized the differences in a comprehensive table.


See also

*
2017 Patient Protection and Affordable Care Act replacement proposals The following is a list of plans which were considered to replace the Affordable Care Act (commonly referred to as the ACA or Obamacare) during the Donald Trump administration. The plans were considered after the Republican Party (United States) ...
* World's Greatest Healthcare Plan of 2017


References


External links

{{Commons category
H.R. 1628: American Health Care Act of 2017
(131 pages), as passed by the House of Representatives on May 4, 2017. *
American Health Care Act of 2017: Report of the Committee on the Budget, House of Representatives, to accompany H.R. 1628, together with Minority Views
(H.Rpt. 115–52, March 20, 2017), an 814-page report that includes section-by-section analysis, arguments for and against (by Republicans and Democrats), and the cost estimates from the non-partisan
Congressional Budget Office The Congressional Budget Office (CBO) is a List of United States federal agencies, federal agency within the United States Congress, legislative branch of the United States government that provides budget and economic information to Congress. Ins ...
(CBO). ''This only cover
the March 20, 2017, version of the bill
'. For the version that passed in the House, no analysis, dissenting views, or CBO estimates were reported, but you can find the official summaries of the amendments in the Rules Committee's reports
H.Rpt. 115-58
(March 24, 2017) an
H.Rpt. 115-109
(May 3, 2017). Legislation attempting to reform or repeal the Affordable Care Act United States federal reconciliation legislation Proposed legislation of the 115th United States Congress Internal Revenue Code Wealth in the United States