Obamacare repeal is done.
On Friday afternoon, almost at the exact same time the House of Representatives was set to vote on the American Health Care Act (AHCA), the bill was suddenly pulled from the floor, and the House went into recess. House Speaker Paul Ryan later confirmed at a press conference that the bill is effectively dead.
“Obamacare is the law of the land,” Ryan said. “We’re going to be living with Obamacare for the foreseeable future.”
By the latest count, the bill was facing tough odds. Rep. Chris Collins (R-NY) told Vox, “I think if it passes, it passes by two. I have 21 hard no’s and another 20 on the bubble. Let's put it this way: They want to vote no. If it goes down, it goes down by 40.”
On Thursday, Ryan and President Donald Trump said they were done negotiating with House Republicans and had finalized the text of the AHCA. They planned to force the House to vote on the bill Friday afternoon, even though the nonpartisan Congressional Budget Office has not yet analyzed the latest proposal to find out how much it will cost or how many people it will cover. This appeared to prompt a growing series of defections from members holding seats in districts Hillary Clinton won in November, who’ve grown nervous about a process overwhelmingly dominated by the concerns of the furthest-right members of the caucus.
House Republicans signaled for the past few days that they don’t have the votes. But Trump demanded a vote for Friday to get this issue over with. As Collins, a Trump ally, told reporters, “The president wants a vote tomorrow.” He added, “If it doesn’t pass, we’re moving beyond health care.”
And then, as the House prepared to vote, the bill was yanked.
What the AHCA would have done
The AHCA kept some of the provisions and structure of Obamacare. Insurers still have to cover people with preexisting conditions, although they can charge more to people who have a break in insurance coverage. Children can still stay on their parents’ insurance until they turn 26. And the federal government still provides some help to people buying insurance coverage on the individual market.
But the bill also makes big changes that, overall, would make it harder for low-income people, especially older low-income people, to afford coverage. For people who are still able to buy health insurance, the coverage they get might leave out some crucial health services:
- Compared with Obamacare, AHCA provides much lower subsidies for those who buy private insurance on the individual market, especially people who are low-income. The Kaiser Family Foundation estimates that, on average, the subsidies in this plan are 36 percent lower than those in current law. This means it would become harder for people who earn about $20,000 or $30,000 a year to afford coverage if they don’t get it at work.
- The bill further alters the individual market by repealing the federal government’s definition of “essential health benefits” that all plans sold on the individual market must provide, as well as similar provisions for Medicaid plans. (Read Julia Belluz’s explainer for the full details.) Obamacare required all plans to cover hospitalization, maternity benefits, prescription drugs, and ambulance transportation. Under AHCA, the federal government wouldn’t require insurers to offer those benefits anymore; it would be up to the states.
- It also changes and cuts Medicaid. Obamacare expanded Medicaid to cover all Americans who earn less than 138 percent of the federal poverty line (about $15,000 for an individual). Before the health care law, only certain low-income people could use the program: pregnant women below a certain income threshold, for example, or the blind and other people with disabilities. AHCA would keep the Medicaid expansion, but phase it out in the next few years. At that point, states would have to stop enrolling people, and anyone who fell off the program — perhaps because their income went up, or they simply forgot to enroll — would not be allowed back on.
- AHCA changes the rest of Medicaid too. It would effectively cut the program over time by moving toward a “per capita cap” or block granting system that essentially gives states less money for Medicaid plans. (Read Dylan Matthews’s explainer for the full details.)
- There are other important changes in the AHCA that advantage higher-income people and disadvantage low earners. Obamacare did not give any financial help to individuals who earn more than about $48,000. AHCA will give the same subsidies to everybody who earns less than $75,000. That’s a huge change from the current health care law: Right now, someone who earns $20,000 gets way more help than someone who earns $40,000.
In total, the Congressional Budget Office estimated that 24 million people would lose insurance as a result of the bill by 2026. But that was before Republicans amended it.
Republicans changed the AHCA to shore up support
Before the vote, Republicans amended the bill to try to shore up conservative support, adding new provisions:
- Repealing essential health benefits for individual markets as a concession to the conservative Freedom Caucus
- Putting $15 billion more into a “flexibility fund” for states as a concession to the more moderate Coverage Caucus
- Keeping the 0.9 percent tax on Medicare for high-income earners for six more years to raise more revenue
“That,” Collins said, “is the bill.”
Congressional Republican leaders didn’t seem to love Trump’s “full steam ahead” plan for a vote on the bill on Friday. Jonathan Swan of Axios reported that they “think they're still short on the vote count,” and fear that “if the bill comes to the floor with less than the required number, the vote will collapse on them.” But Trump wanted it, so it was apparently happening, even though no deal had yet been reached with either holdout group, and the newest changes didn’t have a CBO score.
The changes weren’t enough enough — and the bill collapsed
Plan A was to hold a vote on the AHCA for March 23, a date that was picked well before Republicans had rounded up the necessary votes or even finalized the bill’s text. House Minority Leader Nancy Pelosi today characterized this as a “rookie mistake” on Trump’s part, though as she also said, the calendar appears to have been driven by symbolism. The original Affordable Care Act (also known as Obamacare) was passed on March 23, 2010, after more than a year of agonizing debate, and Republicans liked the idea of passing repeal on its seventh anniversary.
A very droll Pelosi on Trump's rookie errors. pic.twitter.com/q5AI8Xptlh— southpaw (@nycsouthpaw) March 23, 2017
To meet that schedule, they passed the bill rapid-fire through three different committees in marathon sessions, blocking amendments on party-line votes even though House leaders knew they didn’t yet have majority support for the bill. The plan was to conduct negotiations on changing the legislation outside of the political process, then bring the final text to the floor as a “manager’s amendment” to be voted on shortly before final passage.
But it was clear Thursday that Republicans didn’t have the votes to pass the bill. On the one hand, the bill appears to be becoming toxically unpopular as more and more of the public sees that the legislation amounts to neither the full repeal the hardcore right craves nor the “terrific” health care alternative that Trump promised. On the other hand, the bill appears to be well short of the 50 votes it would need to pass the Senate, so members may be reluctant to cast a tough vote on legislation that is unlikely to ultimately succeed.
But with the arbitrary anniversary deadline slipping, a new arbitrary deadline moved to center stage. Trump was impatient with the process and reportedly annoyed at Ryan for having convinced him to get behind the idea of making Obamacare repeal his top priority. So he ordered a do-or-die vote called for Friday afternoon.
Then, the Friday vote was abruptly canceled, as Republicans failed to whip enough votes for the bill. And so, Ryan concluded, Obamacare remains the law of the land.