Effort to “Repeal and Replace” Obamacare Under Trump
(January to July 2017)
GOP House Bill: The American Health Care Act
The rushed  and unpopular [2,3] American Health Care Act (AHCA) of 2017  was passed in the House of Representatives on May 4 under the leadership of Rep. Paul Ryan (R-WI) by a narrow margin of 217–213 .
AHCA was the Republican effort to “repeal and replace” the Affordable Care Act (ACA), also known as Obamacare.
The House bill would have uninsured 23 million people; drastically reduced federal funding for Medicaid; decreased federal subsidies for health insurance premiums (primarily affecting low-income and elderly individuals); cut taxes for high-income earners; broadened state waivers to facilitate opting out of the federal marketplace; changed essential health benefit requirements and coverage levels by insurers; dramatically increased costs for people with pre-existing conditions; allowed insurers to charge senior citizens up to five times more than younger adults (compared to a maximum of three times more under Obamacare); and decreased the federal budget deficit by 1% over ten years, among other reforms .
GOP Senate Bill: The Better Care Reconciliation Act
In the Senate, the House’s AHCA was substituted with a modified version of the bill called the Better Care Reconciliation Act (BCRA) of 2017 .
Senate Majority Leader Mitch McConnell (R-KY) led a working group of initially only 13 men [8,9] to draft the bill behind closed doors under strict and unprecedented secrecy . This secretive process drew heavy criticism from both Democrats and Republicans alike .
The Senate’s BCRA draft bill was eventually unveiled on June 22 . It was broadly similar in structure to the House’s AHCA bill and would have uninsured 22 million people; rolled back Medicaid expansions more slowly but with deeper funding cuts; allowed insurers to offer stripped-down cheaper plans; on average increased insurance premiums until 2020 (and then lowered thereafter due to insurers covering a smaller share of health benefits); increased insurers’ benchmark plans’ deductibles; increased total out-of-pocket costs that would have disproportionately burdened low-income earners; expanded the option to use tax-deferred health savings accounts; potentially let states lift Obamacare’s ban on limiting the number of insurance claims allowed each year; eliminated all except two Obamacare taxes on the wealthy; insufficiently increased funds to address the opioid epidemic; and set aside a relatively small amount of federal funds to help stabilize health insurance markets, among many other changes [13,14].
Discord Among Senate Republicans
Overall, there were at least two major versions and as many as five additional amendments or alternate versions of the GOP health care bill , mostly because Republicans were unable to come to a consensus on which provisions to include in the final piece of legislation.
Moderate conservatives believed changes made by McConnell’s health care bill were too drastic, while the hard-line conservative Freedom Caucus argued the bill didn’t go far enough to repeal Obamacare completely [16,17].
Widespread Opposition to Trumpcare
In the final month leading up to a Senate vote, there was dismal public support. As low as 1 in 6 Americans (17%) approved of the GOP health care bill; among Republicans alone, only about 1 in 3 polled (35%) were in favor of the BCRA [18,19].
Notably, almost every major medical organization, scores of patient advocacy groups, some of the largest hospital networks in the country, some catholic church leaders, an actuarial society, and a few major insurers themselves spoke out to oppose the Senate GOP health care bill [20,21].
Ready or Not, Senate Forces Trumpcare Vote Under Tight Deadline
Before adjourning for summer recess, the Senate pushed for a series of three major chamber votes in the last week of July despite ongoing disagreements.
On July 25, a “motion to proceed” to officially advance the health care bill to the Senate floor barely passed 51–50 after Vice President Mike Pence cast a tie-breaking vote [22, 23].
Just hours later, a few critical provisions of the BCRA bill were found to be in violation of budget reconciliation rules, a special procedure previously invoked by McConnell to use the budget drafting process as a vehicle to pass health care law [24,25].
This legislative approach required all bill modifications to be effectively neutral overall on net spending and debt, but in return allowed Republicans to 1.) avoid a block (filibuster) by Democrats to prevent bringing their bill to a vote, and 2.) pass the bill with just 51 votes (a simple majority) instead of the usual 60 votes (a supermajority). This strategy was necessary because Republicans only held 52 seats in the Senate.
After failing to meet budget reconciliation requirements, the Senate’s health care bill to repeal and replace Obamacare essentially fell apart and was rejected 43–57 .
On July 26, a secondary and less ambitious effort to repeal Obamacare—a “partial repeal” called the Obamacare Repeal Reconciliation Act (ORRA), which would have increased the number of uninsured people by 32 million, caused premiums to soar, and eventually collapsed the marketplace without further intervention [27,28]—also failed to pass.
On July 28, Republicans made a last-ditch effort to write a slimmed-down eight-page “skinny repeal” bill revealed merely hours before a final vote . The crux of the bill would have repealed the individual mandate—the cornerstone of Obamacare requiring purchase of health insurance or payment of a penalty. The purpose of the skeleton bill was to simply keep the repeal process alive and to pass something to allow further negotiation later on in the House.
Trumpcare Defeated… For Now?
In dramatic fashion, the GOP repeal effort was narrowly rejected 49–51 as Senator McCain (R-AZ) cast the final ‘No’ vote, joining Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK) to defeat the proposal [30,31].
1. Berman, R. (May 25, 2017). Republicans Reckon With a Rushed Health-Care Vote. Retrieved from TheAtlantic.com on September 4, 2017.
2. Quinnipiac University Poll (March 23, 2017). U.S. Voters Oppose GOP Health Plan 3-1, Quinnipiac University National Poll Finds; Big Opposition To Cuts To Medicaid, Planned Parenthood. Retrieved from QU.edu on September 4, 2017.
3. Kirzinger, A., DiJulio, B., et al. (May 31, 2017). Kaiser Health Tracking Poll - May 2017: The AHCA’s Proposed Changes to Health Care. Retrieved from KFF.org on September 4, 2017.
4. GovTrack (July 28, 2017). H.R. 1628 (115th): American Health Care Act of 2017, Summary. Retrieved from GovTrack.us on September 4, 2017.
5. Willis, D. (May 4, 2017). House Vote 256 - Passes American Health Care Act, Repealing Obamacare. Retrieved from ProPublica.org on September 4, 2017.
6. Congressional Budget Office and Joint Committee on Taxation (May 24, 2017). H.R. 1628, American Health Care Act of 2017. Retrieved from CBO.gov on September 4, 2017.
7. United States Senate Committee on the Budget (June 26 and July 20, 2017). Discussion Draft - Better Care Reconciliation Act (BCRA). Retrieved from Senate.gov on September 5, 2017.
8. Pear, R. (May 8, 2017). 13 Men, and No Women, Are Writing New G.O.P. Health Bill in Senate. Retrieved from NYTimes.com on September 5, 2017.
9. Phillips, A., Fischer-Baum, R., Schaul, K., and Urmacher, K. (Updated July 25, 2017). Senate Republicans are scraping together votes to debate the health-care bill. Retrieved from WashingtonPost.com on September 5, 2017.
10. Rovner, J. (June 14, 2017). The Senate’s Secrecy Over Health Care Was Decades in the Making. Retrieved from TheAtlantic.com on September 5, 2017.
11. Kaplan, T. and Pear, R. (June 15, 2017). Secrecy Surrounding Senate Health Bill Raises Alarms in Both Parties. Retrieved from NYTimes.com on September 5, 2017.
12. Kurtzleben, D. (June 22, 2017). Senate Republicans Reveal Long-Awaited Affordable Care Act Repeal Bill. Retrieved from NPR.org on September 6, 2017.
13. Levey, N. and Kim, K. (March 8, updated July 13, 2017). A side-by-side comparison of Obamacare and the GOP’s replacement plans. Retrieved from LATimes.com on September 5, 2017.
14. Congressional Budget Office and Joint Committee on Taxation (June 26, 2017). H.R. 1628, Better Care Reconciliation Act of 2017, Cost Estimate. Retrieved from CBO.gov on September 6, 2017.
15. Kaiser Family Foundation Health Reform Comparison Tables (May–July 2017). Compare Proposals to Replace The Affordable Care Act. Retrieved from KFF.org on September 6, 2017.
16. Karlin-Smith, S. (July 2, 2017). Republicans can’t agree on where Senate Obamacare repeal stands. Retrieved from Politico.com on September 6, 2017.
17. Struyk, R. (Updated July 14, 2017). Why Senate Republicans can’t agree to repeal Obamacare, in charts. Retrieved from CNN.com on September 6, 2017.
18. Cillizza, C. (June 29, 2017). A number certain to strike fear in the hearts of Senate Republicans. Retrieved from CNN.com on September 6, 2017.
19. Kaiser Health Tracking Poll (July 14, 2017). July 2017: What’s Next for Republican ACA Repeal and Replacement Plan Efforts? Retrieved from KFF.org on September 6, 2017.
20. Marcus, M. (Updated June 26, 2017). Major medical groups call for rejection of Senate health bill. Retrieved from CBSnews.com on September 6, 2017.
21. Congressman Cooper, J. Groups opposing the American Health Care Act. Retrieved from House.gov on September 6, 2017.
22. Kaplan, T., Pear, R., and Abelson, R. (July 25, 2017). Senate Health Care Decision: Pence Breaks Senate Tie. Retrieved from NYTimes.com on September 6, 2017.
23. Stark, L. (July 25, 2017). Vote tally: How each senator voted on GOP health care motion. Retrieved from CNN.com on September 6, 2017.
24. Reich, D. and Kogan, R. (November 9, 2016). Introduction to Budget “Reconciliation”. Retrieved from CBPP.org on September 7, 2016.
25. Committee for a Responsible Federal Budget (December 6, 2016). Budget Process: Reconciliation 101. Retrieved from CRFB.org on September 7, 2017.
26. Fox, L., Lee, MJ., Mattingly, P., and Barrett, T. (Updated July 26, 2017). Senate rejects proposal to repeal and replace Obamacare. Retrieved from CNN.com on September 6, 2017.
27. Jost, T. (July 19, 2017). The Obamacare Repeal Reconciliation Act: What Repeal And Delay Would Mean For Coverage, Premiums, And The Budget. Retrieved from HealthAffairs.org on September 6, 2017.
28. Congressional Budget Office and Joint Committee on Taxation (July 19, 2017). H.R. 1628, Obamacare Repeal Reconciliation Act of 2017, Cost Estimate. Retrieved from CBO.gov on September 6, 2017.
29. Lee, MJ., Fox, L., Barrett, T., Mattingly, P., and Killough, A. (July 28, 2017). GOP Obamacare repeal bill fails in dramatic late-night vote. Retrieved from CNN.com on September 6, 2017.
30. Pear, R. and Kaplan, T. (July 27, 2017). Senate Rejects Slimmed-Down Obamacare Repeal as McCain Votes No. Retrieved from NYTimes.com on September 6, 2017.
31. Parlapiano, A., Andrews, W., Lee, J., and Shorey, R. (Updated July 28, 2017). How Each Senator Voted on Obamacare Repeal Proposals. Retrieved from NYTimes.com on September 6, 2017.