House Republicans held together just enough on Thursday to pass their partial Obamacare replacement, a surgically repaired bill that a critical mass of conservatives and moderates blocked until they became more comfortable with the final product in recent days.
The narrow vote of 217-213 was hard-earned, as Vice President Mike Pence, the right-wing House Freedom Caucus and its moderate complement the Tuesday Group, a surprise rank-and-file defector and a former key committee chairman, and President Trump himself all exerted pressure on a process that had been cracking since March. But the American Health Care Act was salvaged with several major amendments, the last being a modest $8 billion allocation over five years to support patients with pre-existing conditions. Some lawmakers demanded the money because of a prior amendment that could leave such individuals facing higher premiums in certain states. Conservatives wanted that particular amendment because it fractionally undid an Obamacare regulation they said drives up costs.
Such was the line of dominoes that rapidly fell since House speaker Paul Ryan pulled the legislation on March 24. He was humbled then, but happy on Thursday.
“Today we take the next step to repeal and replace Obamacare,” Ryan said in a floor speech before the vote. “We can continue with the status quo, or we can put this collapsing law behind us, end this failed experiment. Let’s make it easier for people to afford their health insurance.
The AHCA remained controversial for myriad reasons among myriad groups ahead of its approval. Conservative experts like Avik Roy were concerned the bill’s tax credit structure would “price many poor and vulnerable people out of the health insurance market”—an issue that received short shrift in debate of the bill. A topic that received outsize interest was pre-existing conditions, on which conservatives and moderates closed the gap throughout the run of amendments. Allowing states to conditionally waive an Obamacare mandate prohibiting insurers from charging different premiums based on health status—a feature of the so-called MacArthur amendment—could leave higher-risk consumers with higher premiums than they saw under the previous law. The original bill contained funding, as much as $100 billion over nine years, to help those people absorb the additional costs. Then a couple of House Freedom Caucus members attached a $15 billion risk-sharing program to the legislation to address the same matter. Then came the extra $8 billion, backed by Missouri representative Billy Long and former House Energy and Commerce Committee chairman Fred Upton. The maneuvers were sufficient to secure majority support for the AHCA, but not satisfy Democrats, some medical associations, and health policy gurus across the ideological spectrum.
The final draft wasn’t put to the statistical test: The Congressional Budget Office didn’t score it, and its evolving provisions were evaluated for their sense more than their actuarial effectiveness. Previous analyses of the bill didn’t necessarily help clarify it, however. The mainstream media widely misinterpreted an initial CBO estimate to state that the legislation would force 24 million Americans off their insurance. What the CBO actually projected was that 24 million fewer people would possess coverage by 2026 than were forecast to have it under Obamacare. It’s the difference between real people with real insurance and imaginary people with imaginary insurance. There’s no such thing as kicking someone off hypothetical coverage. And the CBO, by its own admission of incapacity, has a spotty track record of forecasting this particular number to begin with.
Still, the figure was reported with incorrect context, Democrats seized on it, and the legislation was sunk—largely for an unmeritorious reason instead of other legitimate and obvious critiques. If you want to know why the American Health Act was never debated lucidly, consider this episode Exhibit A.
The bill accomplishes other Republican priorities: It eliminates most of Obamacare’s taxes, effectively replaces the individual mandate with a penalty for a roughly two-month gap in health coverage, and substantially reforms Medicaid with victories for both conservatives (converting the funding mechanism to states) and moderates (grandfathering in some Obamacare-era policies). But most of the law’s regulatory framework—the real meat of Obamacare—remains, for still unclear excuses and motives of the Senate’s budget rules and the discomfort GOP members have toying with the regulations that underpin the law’s popular pre-existing conditions provisions.
The AHCA now advances to a different legislative challenge: The upper chamber, where Republicans hold a small majority with possibly problematic moderates. The Senate also has unique standards for permitting arguably non-budget-related items—such as those in the MacArthur amendment—which could pose an issue for considering the bill in its current form.
