Following a week of amendments and last-minute deal making, and after postponing a scheduled March 23 vote, the House leadership cancelled a vote on H.R. 1628, the American Health Care Act (AHCA), legislation to repeal and replace the Affordable Care Act.  House Speaker Paul Ryan (R-WI) noted: “We’re going to be living with Obamacare for the foreseeable future.”

At the outset of last week, the House Republican leadership outlined, and the House Rules Committee approved, a rule incorporating a  “manager’s amendment” to H.R. 1628, as forwarded by the House Budget Committee on March 16 (see committee report here).  This “manager’s amendment” was intended to address concerns of conservative Republicans aligned with the House Freedom Caucus as well as moderate Republicans.  These changes to the original AHCA included provisions to:

• Terminate the ACA Medicaid expansion for childless, non-disabled, non-elderly, non-pregnant adults up to 133 percent of the Federal Poverty Level (FPL) and sunset the ability of States to cover adults above 133 percent FPL at the end of 2017.
• Allow States to impose a work requirement as a condition of Medicaid coverage for non-disabled, non-elderly, non-pregnant adults.
• Allow States to opt for a block grant rather than per-capita cap to fund traditional, non-expansion adult and children.  (Block grants would not be available for the elderly and disabled.) 
• Modify the Medicaid matching formula for New York, prohibiting Federal reimbursements for Medicaid funds collected by counties.
• Move implementation of the “Cadillac Tax” from 2025 to 2026, and accelerate repeal of all other ACA taxes from 2018 to 2017.
• Attempt to add additional funding for Americans aged 50-64 and provide additional funding for the Patient and State Stability Fund.

On March 23, the Congressional Budget Office (CBO) released a score for the revised version of the AHCA, noting that the amended bill would provide $150 billion in deficit reduction over 10 years, down from $337 billion over 10 years in the original AHCA.  CBO estimated that the revised bill would result in similar impacts for health insurance coverage and premiums as would the initial AHCA bill - 14 million more individuals would be uninsured in 2018, increasing to 24 million in 2026.  The amended AHCA would result in an increase in average premiums in the nongroup market before 2020. 

After negotiations and meetings with President Trump and Vice President Pence, the House rescheduled a planned March 23 vote to March 24 and indicated further amendments would be added to the AHCA, in an effort to secure the necessary votes for passage.  These amendments would:

• Delay the repeal of the extra 0.9 percent Medicare tax on wealthy enrollees  ($200,000 for single filers; $250,000 for joint filers) for six years, generating $63 billion in revenue.
• Increase flexibility of the Patient and State Stability Fund, to allow it to be used for reducing the cost of coverage in the individual and small group markets, and add $15 billion to the Fund for maternity, mental health, and substance abuse purposes.
• Require States, rather than the Secretary of HHS, to define Essential Health Benefits with respect to plans offered in a particular State.

On Friday, March 24, facing unified Democratic opposition and falling short of the 216 Republican votes needed to approve H.R. 1628, House Republican leaders pulled the bill from the schedule and adjourned.  Congressional Republicans and the Trump Administration will evaluate how to proceed on healthcare issues.  HHS and CMS may still pursue regulatory changes to the ACA, which was the second of the proposed “three bucket” approach to ACA repeal and replace.