Steps to pass the American Health Care Act

January 12 and 13

Senate and House set up reconciliation process

Even before President Trump was inaugurated, Republicans in Congress took steps toward repealing Obamacare, instructing committees to begin what’s called a budget “reconciliation” process to dismantle the law. Reconciliation instructions give guidance for the total spending, revenue or debt limit changes that the bill must meet.

The Senate vote followed a late-night series of mostly symbolic votes forced by Democrats to get Republicans on the record on several controversial issues. The House passed it a day later, with all Democrats and nine Republicans voting “no.”

March 7

Bills introduced in House

After a month of debate among Republicans about the best path forward, House leaders unveiled their proposal, known as the American Health Care Act. The legislation began as two bills drafted by separate House committees.

Republicans planned to advance the legislation through a budget process called reconciliation, which wouldn’t be subject to a filibuster in the Senate but does limit what type of provisions can appear.

March 9

Ways and Means Committee approves bill

The committee was the first to answer the reconciliation instructions by advancing health-care policy changes. Republicans on Ways and Means approved the measure in a 4:30 a.m. party-line vote after 18 hours of debate.

March 9

Energy and Commerce Committee approves bill

After 27 hours spent debating the proposal, Energy and Commerce approved its portion of the bill on Thursday along party lines. It includes Medicaid revisions that transform the program into a fund for the states, depending on how many people they have enrolled. The final legislation will need to strike a difficult balance, weighing the concerns of Republicans from states that accepted the Medicaid expansion against those hoping to see it end sooner than the current bill’s 2020 deadline.

March 13

Bill scored by Congress’s budget analysts

A Congressional Budget Office analysis of the bill estimated that 14 million additional people would be uninsured next year if AHCA were enacted. That number jumps to 24 million by 2026, partially because federal Medicaid dollars per person would be capped, imperiling the expansion of the program that took place in 31 states and the District of Columbia. The report also estimated a $337 billion reduction in the federal budget over 10 years.

The CBO is a nonpartisan scorekeeper that predicts the impact of legislation. Two House committees voted the legislation through before the CBO released its analysis, prompting criticism from Democrats.

Before it was released, some Republicans tried to preemptively downplay or discredit the report, with others calling on their House colleagues to pump the brakes and wait for the budget estimate before proceeding.

Related: Obamacare revision would reduce insured numbers by 24 million

Thursday, March 16

Budget Committee combines the legislation

The Budget Committee voted 19-17 to advance the American Health Care Act, the GOP’s health care replacement bill. Three Republicans opposed the motion, all of whom are members of the conservative House Freedom Caucus.

The committee combined the bills previously marked up by other committees into one piece of legislation, which is on track to reach the House floor.

The Budget Committee was not permitted to make substantive changes to the legislation’s content but did recommend amendments for the Rules Committee to consider. Rep. Diane Black (R-Tenn.), the panel’s chair, served an important procedural role in the process.

Related: Key House panel advances GOP Obamacare overhaul plan

 Week of March 20

Bill amended in the Rules Committee to attract support

Twice in the run-up to a vote on the bill, the Rules Committee passed amendments recommended by the Budget Committee and party leaders. A series of revisions called a manager’s amendment was used to attract more support for the bill that more than 50 Republicans had raised concerns with.

House Speaker Paul D. Ryan (R-Wis.) also admitted that the bill would need changes to help people older than 50 but not yet 65, who often have higher health costs, but have not yet reached Medicare eligibility. It was a concession to moderate Republicans who feared rising costs for seniors could endanger their electoral prospects, but widened the gap with conservatives who referred to the bill as ‘Obamacare Lite.’

Related: Eleven changes to the original health-care bill aimed at wooing moderates and the far-right

Friday, March 24

House leadership pulls the vote

Ryan decided against bringing the bill to a vote amid a chorus of complaints from the House Freedom Caucus that the bill didn’t constitute a true ACA repeal, as well as from moderate Republicans concerned about how many Americans could lose insurance coverage. The speaker told reporters that his party “came really close today, but we came up short.”

About a month and a half after the defeat, Republicans have resurrected the bill with amendments to coax more conservative support.

Thursday, May 4

House passes bill, 217 to 213

A full House vote Thursday narrowly approved the bill, which had taken a more conservative turn since it nearly came to a vote in March. Many members of the House Freedom Caucus supported the legislation after they helped kill the previous version of the bill. Twenty Republicans, mostly moderates, voted against it. The vote took place after it cleared a procedural vote in the Rules Committee late Wednesday night.

The bill’s changes, including an option for states to opt out of the Affordable Care Act’s requirements for covering preexisting medical conditions, concerned moderate Republican lawmakers. After saying he would vote “no” on the bill because of the provision, Rep. Fred Upton (R-Mich.) introduced an amendment that would provide $8 billion over five years to help cover people with preexisting conditions. It cleared the way for passage of the legislation, and Upton voted yes.

Related:  House Republicans narrowly pass controversial bill to revise Affordable Care Act

Latest action: June 22

Draft of Senate-rewritten bill released

GOP leadership released a draft of its health-care bill after weeks rewriting the House’s version in secret, prompting complaints from its own conference.

Four Republican senators almost immediately expressed concerns with the bill: Ted Cruz (Tex.), Dean Heller (Nev.), Ron Johnson (Wis.) and Rand Paul (Ky.). Senate Majority Leader Mitch McConnell (R-Ky.) postponed planned votes on the bill until after the Fourth of July Recess.

A Congressional Budget Office analysis estimated that 22 million additional people would be uninsured under the Senate plan by 2026 if the Senate bill were enacted. The report also estimated a $321 billion reduction in the federal budget over 10 years — largely through cuts in federal help for states to pay for Medicaid.

Related: What the Senate bill changes about Obamacare


Bill must pass Senate

Because Republicans hope to pass this legislation under the less-onerous budget reconciliation process, which would allow it to pass the Senate with only 51 votes, lawmakers must make the bill comply with the Senate’s “Byrd Rule.” Generally, the rule says a reconciliation bill must relate to the budget, which means some of the Affordable Care Act’s provisions cannot be addressed via this process because they do not deal with taxes or spending. It also stipulates that the law cannot add to the deficit in the long term (10 years after it is implemented).

Senate Republican Conference Chairman John Thune told Roll Call that GOP leadership is having ongoing discussions with the Senate parliamentarian to ensure the bill they bring to the floor will pass the Byrd Rule.

Republicans have a 52-48 majority in the Senate. Since no Democrats or Independents are expected to vote to repeal Obamacare, Republicans can afford to lose just two of their own to successfully pass the bill. (Vice President Mike Pence would cast a tiebreaking vote if two defected.)

That’s not much room for dissent. Moderate and more conservative Republicans have publicly raised concerns about the bill, suggesting changes appealing to both sides of the party will be necessary.

Related: Trump, Senate leaders attempt to regroup after postponing vote to overhaul Obamacare

Differences in House and Senate bills must be resolved

If the Senate does not pass the House’s exact version of the legislation, the two bills must be reconciled.

It’s common for a group of lawmakers from the two chambers to come together in a conference committee to iron out the differences between the bills. The result is then presented to both chambers for a final up-or-down vote. Alternatively the House could vote on the Senate version, bypassing the conference committee step.

President signs the bill into law

If Trump sours on the bill, he could decide to veto — effectively killing the legislation. Or he could sign it, kicking off the next phases of the Republican effort to dismantle Obamacare: further regulatory actions and additional legislation.

Last year, an Obamacare repeal bill cleared both houses but was promptly vetoed by President Barack Obama in defense of his signature policy accomplishment.

Administrative actions

Beyond the AHCA, Republicans have outlined two other phases of health-care overhaul. The first of those is an easing of regulations, begun by Trump’s Jan. 20 executive order telling federal agencies to “minimize the unwarranted economic and regulatory burdens” of Obamacare. Regulatory reforms could include narrowing the list of benefits that Obamacare requires insurers to cover.

Additional legislation

Because only budget-related items are allowed in a reconciliation bill, Republicans also plan to address other aspects of the overhaul with at least one other piece of legislation. This bill would be subject to the filibuster, requiring 60 votes — and at least eight Democrats — to get to a Senate floor vote. It could include allowing people to buy insurance across state lines.

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