One small step for Republicans towards repeal of the Affordable Care Act

As the American Health Care Act has passed through the House of Representatives, Allan M. Joseph and William H. Seligman assess what impact this will have.

After its apparent failure in April, the American Health Care Act (AHCA) has recently been revived by the Republicans in the US House of Representatives, who passed a revised version of the bill by a narrow margin of 217-213 yesterday afternoon. This is a large and complex bill that not only repeals President Obama’s landmark Affordable Care Act (ACA) but also enacts cuts to Medicaid (the government program for those with low-incomes and disabilities) and implements a new scheme for providing health insurance subsidies. The likely effects of the AHCA as it was in April have been well-summarised.

Of particular interest, however, are the two amendments that won enough support from far-right conservatives (represented in the House of Representatives by the Freedom Caucus) and moderates (represented in the House by the Tuesday Group) to give House Republicans a working majority.

First was the MacArthur-Meadows Amendment, negotiated by the leaders of the respective caucuses. This amendment would allow states, if they so wished, to apply to the federal government for exemptions from two of the clauses of the ACA that expanded coverage. Under the ACA, insurance companies were required to cover comprehensive benefits for all recipients. The ACA also prevented insurance companies from setting the prices that patients pay for their insurance based on their level of health. The MacArthur-Meadows Amendment gives states the option of dropping these requirements for those who do not maintain continuous coverage; it aims to bring down premiums for the healthy by reducing cross-subsidization of the sick. Yet this amendment has raised significant concerns—most notably that, according to the Brookings Institution, it would not even provide protections to the continuously-insured.

The Upton Amendment, on the other hand, was intended to win over moderate conservatives by providing an additional $8 billion in funding for patients in states whose governments apply for waivers under the MacArthur-Meadows Amendment. This funding is aimed at insuring those who would otherwise lose coverage under the MacArthur-Meadows Amendment in so-called high-risk pools. These pools combine individuals with certain or likely high medical expenses to drive down health insurance costs for healthier groups of people who are insured under standard insurance. The evidence from high-risk pools that were in existence prior to the ACA suggests that they are no panacea, leaving many uncovered or with tight coverage restrictions. The $8 billion appropriated by this amendment is almost certainly insufficient to support the number of people who would be affected by the MacArthur-Meadows Amendment and we can therefore expect lengthy waiting lists and high uninsurance rates in states that apply for waivers. As Richard Figueroa, a senior administrator for the California high-risk pool program, told the New York Times “there were people literally dying on the waiting list.”

Perhaps the most notable feature of these amendments, however, is the speed with which Republicans adopted them before voting. Under normal procedures, after introducing or amending pending legislation, the House and Senate wait for analysis from the Congressional Budget Office (CBO), Congress’s non-partisan “scorekeeper.” CBO generally reports policy impacts (e.g. on access to insurance, total costs, and government spending), and its results often drive lawmakers’ and the public’s impressions of the policy. In an extraordinary break, however, the House of Republicans adopted and voted for these amendments well before CBO could prepare analysis, in essence “flying blind” in enacting these policies. Therefore, key questions are still unanswered—not least how many people with pre-existing conditions will lose their coverage.

The story of the AHCA is far from over. It must still pass the Senate, where it faces complicated procedural questions and a narrow path to passage. While Democrats will likely vote against it en bloc, it will be difficult for Senator Mitch McConnell (the leader of the Republicans in the Senate) to unite his party with members so spread out along the conservative spectrum. Any changes passed by the Senate must then be ratified by the House; those changes are likely to moderate the bill and endanger votes from the Freedom Caucus on second consideration. There is a long way to go, but do not underestimate the significance of this vote.

Allan M. Joseph studies health policy at the Harvard T.H. Chan School of Public Health and is a medical student at the Warren Alpert Medical School of Brown University.



William H. Seligman completed his Foundation Programme training in the Severn region before embarking on the Master of Public Health program in health policy at the Harvard T.H. Chan School of Public Health. He was previously a Legislative Intern in the United States Senate.

Competing interests: None declared.