House Republicans passed their Obamacare repeal and replacement bill Thursday in a miraculous turnaround for legislation that had seemed dead and buried for the past month.
The bill would make deep and sweeping changes to the American health care system. Broadly, the bill loosens Obamacare’s rules on what insurance companies must offer in their plans, opening the door for plans that are cheaper but offer weaker coverage.
Most controversially, the American Health Care Act would allow insurance companies to charge people with pre-existing conditions higher premiums than healthy people in some states that choose to do so.
The bill passed narrowly, 217–213, Thursday afternoon and now goes to the Senate, where 51 members will need to pass it before Donald Trump can sign the bill into law. Many provisions, such as stripping federal funding for Planned Parenthood, will become major battles when the Senate gets its hands on the bill. Further changes are all but guaranteed.
Republicans on the House floor cheered as when they saw they had reached their long-sought majority vote. Democrats responded by loudly chanting "nah nah nah nah, hey hey hey, goodbye," a referenced to Republicans being voted out in the midterm election.
"As difficult as it was, we never gave up," said Republican whip Rep. Steve Scalise. "It sets us up to do even bigger things in the future."
Other Republicans were less enthusiastic.
"Am I happy with this bill? No. I think this bill has a lot of issues that have to be worked on. A lot of issues," said Florida Rep. Mario Diaz-Balart, who remained publicly undecided on the bill until the final moments.
But Diaz-Balart said he ultimately voted yes on the bill because rising prices and insurers leaving individual marketplaces meant the status quo would cause more people to lose coverage.
The AHCA, as passed through the House Thursday, rolls back the Obamacare expansion of Medicaid and offers hundreds of billions of dollars in tax breaks. It removes Obamacare’s individual mandate, which requires all Americans to have insurance or pay a penalty, and it replaces subsidies to help people buy insurance with a system of tax credits and soft penalties for dropping coverage.
The passage of the bill through the House is a win for President Trump, who badly needed a legislative achievement to point to. But Republicans in swing districts are putting themselves at risk of vigorous new Democratic attacks. Moderate Republicans made up the majority of GOP no votes on the bill Thursday.
Conservative and moderate factions of the GOP teamed up to oppose the bill in March, when leadership last tried to bring it up for a vote. Since then, it has been substantially amended twice — once to win over conservatives and once to win over moderates.
The amendments worked and narrowly granted Republicans the votes that they needed Thursday. But the two changes are also largely contradictory. The result is a plan that grants states the power to waive Obamacare rules, but is based on the assumption that few states will use this new power.
Conservatives were angry that the original bill did not go far enough in repealing the provisions of former president Barack Obama’s Affordable Care Act. New Jersey Rep. Tom MacArthur’s amendment allows states to waive core insurance company rules such as community rating, which bans insurance companies from charging higher premiums to people with pre-existing conditions. Republicans had vowed many times not to touch pre-existing condition protections. As a backstop, the AHCA relies on setting up high-risk pools to pay for people priced out of the individual insurance market.
Moderate Republicans in vulnerable districts opposed this change and progress appeared stalled. But Republicans found a breakthrough this week, which hinged on a surprisingly small tweak: An amendment from Michigan Rep. Fred Upton added $8 billion in new money to be put towards high-risk pools for states that waive pre-existing condition protections.
The $8 billion would be a drop in the bucket if many states exercise the waivers, but could be sufficient if only a small number do so. Many Republicans, including Upton, have said they expect few states to actually use the waivers.
The amended bill has not been scored by the Congressional Budget Office. Senate leadership said they will wait on that analysis before passing the bill themselves. An earlier CBO analysis of the original bill found that the AHCA will cause 24 million fewer people to have health insurance over the next decade, but it’s not clear how the amendments will affect that number.
Though the bill is politically risky for Republicans, many said there was a bigger risk in doing nothing.
"Donald Trump was elected president on the promise to repeal and replace Obamacare," said Rep. Chris Collins, Trump's liaison in Congress.
"If we weren't able to repeal and replace Obamacare it would have been a bad midterm for us. I think we will at least hold our own or pick up seats."
Here are some of the changes included in the AHCA:
- The bill rolls back the Medicaid expansion, reducing federal payments by $880 billion over the next decade, according to the CBO. The bill cuts $600 billion in taxes that primarily benefit richer Americans over that decade.
- The means-tested Obamacare subsidies that help individuals pay for insurance would be repealed and replaced by a system of tax credits. The tax credits provide individuals $2,000 to $4,000 per year based on age.
- The current draft of the AHCA blocks federal funds from going to Planned Parenthood.
- The bill removes the individual mandate that levels a tax penalty on eligible individuals who do not purchase insurance. Instead, the bill incentivizes staying insured by allowing insurance companies to charge higher rates for one year to people who allow their coverage to lapse.
- While the AHCA does keep guaranteed issue — meaning insurers cannot deny coverage to people with pre-existing health conditions — this is where the waivers become key. If a state waives community rating, then they must offer everyone a plan but could jack up prices to unaffordable rates that could prevent sick people from getting coverage. If they waive essential health benefits, insurance companies can offer cheap, bare-bones plans that do not cover essentials such as emergency care, maternal care, and mental health.
- Republicans insist that these waivers will be used responsibly because states that apply for them must first make their case to the White House that use of waivers will increase the number of insured people with adequate care. The administration would have the discretion to refuse or grant these requests.
- The bill puts $100 billion over 10 years into “state innovation funds” for states to help provide care for high-cost patients. Most of this money will likely go to high-risk pools for those with pre-existing conditions.
Though the vote is a major step, and seemed unlikely for the past several weeks, there is almost universal agreement that the bill cannot pass the Senate as written. Republicans are using what is called the “budget reconciliation” process to pass the AHCA so that they can pass it with a simple majority in the Senate — which means they won’t need any Democrats to agree to pass the bill.
"We'll have a separate process in the Senate and there are features in the House bill that we will build on," Sen. John Thune, a member of GOP leadership, said Thursday. "I'm sure there are probably some parts about the House bill that we like and there are things that I'm sure the Senate will have different ideas about."
House Republicans expect the Senate to make changes and some are hoping they are significant. "I'm sure the Senate will make significant changes," said Rep. Leonard Lance, a moderate Republican who voted no on the bill.
Republican senators said Thursday that in addition to waiting on a CBO score, they will take their time with the health care bill. Sen. John Cornyn, a member of leadership, told reporters earlier Thursday that there is currently "no timeline" for passage.
"We're not going to rush it, but we want to make sure we get it right, but we're going to be very focused on getting it done. Sooner the better," Thune said. "The margin for error is a lot less over here but that being said, you know, I'm confident that our members will be able to produce something that ultimately can get through the Senate."
The challenge for Senate Majority Leader Mitch McConnell now is to amend the AHCA enough to win 50 of 52 Republican Senate votes, knowing that Vice President Mike Pence can provide the 51st vote — without changing it so much that the new additions will lose them the fragile majority in the House.
Alexis Levinson and Emma Loop contributed to this story.
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Paul McLeod is a politics reporter for BuzzFeed News and is based in Washington, DC.
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