On March 24, the AHCA, the House Republican plan to repeal and replace the ACA, was pulled from consideration at the last minute after Speaker Paul Ryan (R-WI) reportedly told President Trump the measure did not have the support of a majority of the U.S. House. The abrupt reversal will be considered by some as a significant defeat for President Trump and congressional Republicans. The bill, which had been proposed by House Republican leadership only a few weeks earlier, struggled to gain support from both the moderate and conservative wings of the Republican caucus.
If the bill had passed the House, it would have faced significant challenges in the Senate where a number of moderate and conservative Senate Republicans expressed concerns with the legislation. The bill would also have faced a procedural challenge in the Senate, where the Senate Parliamentarian would have had to rule on whether the bill produced by the House was eligible for consideration under the expedited reconciliation procedures or if it would need to be amended before moving forward. In particular, the removal of the ACA's ten essential health benefits required by all insurance plans was seen as a challenging inclusion. Initially, House Republican leadership elected not to include this in the legislation for fear that it would fall victim to the "Byrd Rule" that limits the scope of legislation passed through reconciliation. However, the provision was later added after the House Freedom Caucus insisted on its inclusion in exchange for their support, and some Senate Republicans intimated that the Parliamentarian might, in fact, agree to the measure's inclusion.
In the immediate aftermath of the bill's withdrawal, Speaker Ryan said, "Obamacare is the law of the land … We're going to be living with Obamacare for the foreseeable future," and pointedly refused to say whether or when he would move forward with another attempt at a full repeal and replacement. However, after a meeting four days later, Speaker Ryan told reporters "The way I would describe the meeting we just had with our members is we are going to work together and listen together until we get this right." Senate Republican leaders also have made statements indicating they are interested in moving forward with some sort of a bill, but the details of what that would include remain unclear. For instance, earlier this week Senator Lamar Alexander (R-TN), Chair of the Senate Health, Education, Labor and Pensions Committee, said "I don't speak for the House, but there's a sense they were pretty close when they stopped last week. The sense of urgency is the millions of Americans who will be without health insurance, stabilizing the individual market. We said we would do it."
The AHCA was to be only the first step in a three-phase plan by congressional Republicans to repeal and replace the ACA. Phase two was supposed to be a series of administrative actions by the Trump Administration designed to deregulate the non-group market, lower costs and stabilize the market. Many of these planned and already executed actions were premised on the assumption that the ACA would be repealed, and given that it now seems unlikely in the short term, it remains unclear what steps will be taken by the Administration.
There are also a number of other health care measures in the offing that are expected to proceed through regular order in the coming months, including reauthorizations of the Children's Health Insurance Program (CHIP) and the Prescription Drug User Fee Act (PDUFA). However, these proposals, which have had bipartisan support in the past, may become vehicles for Republicans to seek changes to the ACA.
Takeaway: While initial Republican attempts to repeal the ACA through budget reconciliation have come to a (temporary) halt, the health care policy agenda remains full. Expect to see movement on a number of issues related to the ACA from both Congress and the Administration, as well as discussions over the reauthorization of CHIP, PDUFA and possibly chronic care and drug pricing.
