On second try, the GOP has begun the process of repealing the ACA.
A revised version of the American Health Care Act (AHCA), the replacement bill for the Affordable Care Act (ACA) proposed by House Republicans, narrowly passed through the House of Representatives by a vote of 217-213.
An earlier incarnation of the AHCA produced widespread criticism from medical and senior associations, an acidic debate on the House floor, internal conflict within the GOP, and no vote. Lacking the necessary support, the original March 23rd vote on the bill was postponed to the next day before the legislation was pulled from consideration entirely upon the realization that it would not have the support to pass the House.
Internal deal-making sewed up GOP support for the newest version. The most glaring difference between this version of the bill and the previous is the Meadows-MacArthur amendment, allowing states to eliminate the ACA’s pre-existing condition requirements (or protections, depending on which party had the floor).
The early iteration of AHCA was partially sunk by the most conservative elements of the GOP, led by the stalwart House Freedom Caucus, which believed the bill was not a far enough departure from the ACA. Even in March, the draft was amended on several points to appease the Freedom Caucus, but still failed to garner the support it needed. The Meadows-MacArthur amendment helped rope in the Freedom Caucus.
Concessions were made to the party’s center as well. Yesterday, often-moderate Republican Representative Frank Upton of Michigan flipped to favor the bill after $8 billion was written into it to assist those with pre-existing conditions. Upton had been previously critical of the impact the AHCA may have on those individuals, though critics on the other side of the aisle consider that $8 billion concession to still be a drop in the bucket.
While the Republicans worked hard to concede enough points to unite their own ranks behind the legislation, there was no necessity to appease any Democratic support. Twenty Republicans defected and voted against the bill.
Members of the minority party continued their scathing criticism of the bill, reiterating everything they had objected to in March while claiming the state waiver on pre-existing conditions had “made a bad bill even worse.”
Repeating a theme from the first round of debates 6 weeks ago, Democrats in the House followed every Republican statement with a readout of estimated insurance impacts on that Republican’s constituency. Whereas before their numbers were simply the number of people who may lose their insurance in a given district in the absence of the ACA, Democrats today cited estimates of large premium rises in different areas for those with certain pre-existing conditions.
Many Republicans cited the tenuous insurance situation in Iowa as incentive to vote for the bill. Iowa began the year with three providers broadly covering citizens of the state through ACA exchanges. Two have since pulled out, and the last has threatened to as well, which would leave all but 5 of the state’s 99 counties without a single insurance option.
A hot point of contention was an effort to get that revised AHCA on the floor before the Congressional Budget Office (CBO) was able to update its pre-revision appraisals, which featured striking numbers. The CBO at the time predicted tens of millions of Americans would wind up uninsured in the following decade, as many as 24 million, and that it would cut hundreds of millions from Medicaid.
Again today, this most recent AHCA was debated before a corresponding CBO score had been released. Immediately before its successful vote, the House voted overwhelmingly across party lines to remove language that would have exempted members of Congress and their staffs from it.
The bill can be seen as the first major legislative victory for Donald Trump and the new Republican majority. It is still expected to face a fierce battle in the Senate before it can reach Trump’s desk and become law.