After a turbulent week of marathon negotiations to appease enough members of the House Republican caucus to support H.R. 1628, the American Health Care Act (AHCA), leadership in the House of Representatives decided to scrap a vote on the bill roughly an hour before it was scheduled this afternoon. Throughout the day it became increasingly clear that Republicans did not have enough votes to reach the 215-vote threshold for passage in the chamber, with unofficial whip counts showing as many as 50 Republicans expected to vote against the package. The decision to not hold the vote was made by President Trump and House Speaker Paul Ryan (R-WI), both of whom made separate statements at 4:00 p.m. this afternoon that they will be working to figure out next steps, but that the ACA will remain for the foreseeable future.

President Trump noted that he would be open to attempting a repeal of the ACA again with continued failures of the current law. Ryan attributed the bill’s failure to win consensus today due to growing pains of learning how to govern instead of being the opposition party. He noted that “doing big things is hard” and that they would need to find ways for their members to say yes to the good even if it is not the perfect. He and the president agreed that the wise course of action would be to pull the bill and work to find ways to get consensus. However, Ryan said that the failure of this bill is not a prologue for other agenda items of the Republican Party and they will now move forward with tax reform.

Ryan and House leadership had previously stated that they would have a three-pronged approach to health reform: the reconciliation package to repeal and replace certain provisions of the ACA, regulatory reforms implemented by the Department of Health and Human Services (HHS) as instructed by the reconciliation bill, and to use regular order to make additional changes to the ACA with Democratic support. Ryan said that with today’s failure to pass the reconciliation bill that the second phase will be made more difficult and that there are several things that HHS Secretary Tom Price will not be able to do now, such as the Patient and State Stability Fund, which would have created reinsurance risk pools to help bring down costs for consumers, and for which NAHU strongly advocated.

House Republicans scheduled the vote for today following an ultimatum issued by President Trump on Thursday night for the House to either pass the bill on Friday or the Administration would move on from healthcare reform and onto other items on the president’s policy agenda. Following that threat, the House voted 227-189 along party lines on Thursday night to use the “martial law” procedural maneuver that would allow the chamber to bypass the standard one-day waiting period from when the Rules Committee approves the bill and when the bill can be voted on by the full House. The bill would then need a majority of the chamber’s 435 voting members, which was reduced to 429 with five vacancies (four seats previously held by Republicans and one by a Democrat) and the absence of Representative Bobby Rush (D-IL), who was absent to attend funeral services for his wife who passed away last week.

After being passed by the committees of jurisdiction two weeks ago and the House Budget Committee last Thursday, the bill faced several revisions this week in an effort to win the support needed to pass the bill on the House floor. Throughout the night Republicans worked to include language that would win over the support of members of the House Freedom Caucus, the very-conservative group comprised of roughly three dozen members and led by Representative Mark Meadows (R-NC). They asked for the bill to reverse the ACA’s ban on lifetime and annual limits, fully repeal the medical loss ratio (MLR) requirement, separate healthy and sick consumers into separate risk pools, and eliminate language that bars insurers from setting rates based on sex, medical condition, genetic conditions, or other factors. Without these demands satisfied by mid-week, four-in-five Freedom Caucus members voted to reject the bill that leadership posed to them on Wednesday.

Republicans also had to balance these concerns of more moderate members, who were dropping in their support of the bill as concessions were made to the more conservative members. Republican leadership attempted to win support from the Tuesday Group of roughly 40 moderate Republicans by including language in the bill to retain the ACA’s tax on high-income Americans through a six-year extension of the 0.9% Medicare tax for individuals who earn more than $200,000 for individuals and $250,000 for married couples filing jointly. By keeping the tax, they were able to offset $15 billion of the $85 needed to provide additional subsidies for older Americans between the ages of 50-64 to purchase private-market coverage.

These efforts followed a 13-hour hearing by the House Rules Committee on Wednesday to work out the details on manager’s amendments to the bill that would satisfy the warring factions. Late Thursday night, the committee agreed to an amendment designed to win over the support of holdout members of the Freedom Caucus who wanted to see the ACA’s essential health benefits (EHBs) eliminated under the AHCA. The House and Senate had previously stated that the EHBs could not be modified through reconciliation because they didn’t have a budget-relevant element, but they crafted an amendment that partially addressed these concerns. However, that amendment was far from what Freedom Caucus members requested, as to make it budget-relevant the federal government would still mandate the EHBs for plans that would be purchased with federal tax credits. At 9:30 a.m. today, the House Rules Committee voted 9-3 along party-lines to approve the bill, with amendments, for consideration on the House floor.

The Congressional Budget Office (CBO) also released a new analysis on Thursday reflecting the changes made to the bill through that point. That analysis showed no change from its initial projection that 24 million Americans would lose their current health insurance coverage. However, the bill as written would save the government nearly $200 billion less than the initial legislation, with reducing the budget deficit by $150 billion over the next 10 years instead of $337 billion as the previous iteration would.

In light of the AHCA being pulled from a vote in the House, NAHU will use its relationship with Secretary Price to improve market stability through regulations. We would look to use HHS and CMS to make as many changes as possible and many of these actions were discussed during our meeting with Secretary Price, which is covered in the following article. In addition, NAHU would work with our state chapters to pursue 1332 Waivers for the states, which are already a part of the law and allow states more flexibility to modify certain parts of the ACA by modifying the way they comply in a particular state. We expect similar opportunities to work favorably with other agencies that have jurisdiction over our issues as they add political appointees to the career staff already in place.

On the legislative side, we will be working to make changes to the parts of the ACA for which we are able to get consensus on a bipartisan basis. There are many items that both Republicans and Democrats agree on. These legislative items would most likely be in separate pieces of legislation rather than one larger bill. This method takes a little longer, but would most likely be more successful in the long run because it allows different legislators to support the items they are in favor of without having something they don’t like packaged with it, meaning it is easier to get a “yes” vote. Going a little more slowly would ensure that we are able to make changes on the items of biggest concern to NAHU members and their clients.

Meanwhile, the ACA marked its seventh anniversary on Thursday. The healthcare law was signed into law by President Obama on March 23, 2010. That was later amended by the Democrat’s reconciliation vehicle two days later to make several of their own budget-relevant changes to the law and signed by President Obama on March 30. To mark the occasion, former President Obama issued a statement highlighting the more than 20 million Americans who gained coverage under the ACA and encouraged Republicans to improve the law, writing “any changes will make our health-care system better, not worse, for hard-working Americans. That should always be our priority.”