Health Care Reform

Obamacare to Trumpcare (or is it Ryancare?)

US Capitol Building

This is the 6th article in the series Obamacare to Trumpcare. The last article is here.

On March 6, the House Ways & Means Committee and the Energy & Commerce Committee introduced the Republican Budget Reconciliation bill, The American Health Care Act. Here’s a summary of what has happened since then on the road from Obamacare to Trumpcare.

  • Three-prong Strategy. House Speaker Paul Ryan explained that the AHCA is the first prong of a three-prong strategy:
    • Budget Reconciliation bill – American Health Care Act – requires only 51 votes in the Senate
    • Regulatory action – does not require any Congressional action or approval
    • Additional legislation – which will require at least 60 votes in the Senate
  • Ryan also said that Republicans have a “binary choice” (enact this bill or not) and that they need to enact this bill to fulfill their campaign promise for the past six years to repeal Obamacare.
  • Criticism from the left and the right. Both Democrats and far-right Republicans criticized the AHCA. Republicans opposed to the bill labeled it “Obamacare lite.” Democrats opposed to it claimed it would increase the number of uninsured and would increase premiums.
  • President Trump’s support. Initially it wasn’t clear if President Trump was going to support or dump the AHCA, but by March 16th he publicly confirmed his support and was talking with House republican leadership (Paul Ryan and others) about possible amendments to the AHCA to ensure its passage.
  • House Committees. March 9 – the AHCA cleared both the House Ways & Means and the Energy and Commerce Committee and was sent to the House Budget Committee for a mark-up March 16.
  • Joint Committee on Taxation. Projected AHCA cost of $600 billion by 2026 and $700 billion by 2027.
  • CBO score. March 13 – Congressional Budget Office (CBO) released its estimate of the cost and coverage ramifications of the AHCA. CBO projections include:
    • AHCA would reduce the federal deficit by $337 billion, over the 10-year period 2017-26.
    • AHCA would result in 52 million uninsured Americans over that same 10-year period.  The projection under the ACA was 28 million uninsured by 2026; thus, the AHCA is projected to result in 28 million more uninsured than under the ACA.
    • By 2018, 14 million more uninsured people under AHCA than would be under ACA.
    • Average premiums would decrease in 2020 and later, but in 2018 and 2019 would increase by 15-20%.  The lower premiums in 2020 and later would be for younger insureds, while older insureds would pay higher premiums because the AHCA also allows insurers to charge people in the oldest age brackets five times as much as those in the youngest.  (5:1 ratio rather than ACA’s 3:1 ratio)
  • House Budget Committee. March 17 –AHCA passed the House Budget Committee.
  • “Managers’ Amendment.” March 18-19 – Weekend news shows questioned Paul Ryan and other Congressional leaders about a possible “Manager’s Amendment” to the AHCA before it goes to the Rules Committee or the Full House. Possible amendments discussed include:
    • Allow states to impose a work requirement for able-bodied Medicaid recipients
    • Allow states to accept a fixed block grant for Medicaid
    • Increase tax credits for lower-income and older insureds in the individual market
  • Full House vote. Next the AHCA will go to the full House of Representatives – where a vote is scheduled for this Thursday, March 23rd, the seventh anniversary of the date the ACA was signed into law. At this point 17 House Republicans have publicly said they oppose the bill or are leaning that way. If 21 or more Republicans vote against the AHCA, it will not pass in the House.
  • Senate vote. Once the AHCA is passed in the House (assuming it is), it will go the Senate, where some pundits (e.g., Senator Rand Paul) have predicted it will be “dead on arrival” in its current form. Others says we need to wait and see what the final bill from the House looks like and whether enough Senate Republicans agree that the primary goal is to enact Republican health care reform legislation even if not all Republicans agree on all the provisions.

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