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March 18, 2017

Republicans split on vote to advance ACA repeal bill

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The House Budget Committee on Thursday voted 19-17 to advance the House GOP's bill to repeal and replace the Affordable Care Act (ACA)—overcoming "no" votes from three of the committee's conservative members.

The bill, called the American Health Care Act, now heads to the House Rules Committee, where Republicans are expected to introduce amendments to address concerns from both moderate GOP lawmakers, who say the bill goes too far in its cuts to Medicaid, and conservatives, who feel the bill retains too much of the ACA's groundwork.

Committee vote

The House Budget Committee was tasked with combining two separate portions of the health reform bill, which previously had been passed by the House Energy and Commerce and Ways and Means committees, into a single bill. In opening comments, Budget Committee Chair Diane Black (R-Tenn.) said the House bill is "the conservative health care vision that we've been talking about for years," and called on Republicans not to "cut off the discussion."

Ultimately, however, Republican Reps. Dave Brat (Va.), Mark Sanford (S.C.), and Gary Palmer (Ala.), joined the committee's Democrats in voting "no" on the bill.

Under committee rules, each party was able to offer up to seven motions to change the bill. Motions approved by the committee were recommended to the Rules Committee, which determines which amendments are added to the bill before it is considered on the House floor.

The panel unanimously recommended a motion offered by Rep. Tom McClintock (R-Calif.) to change the way tax credits are issued under the bill to lower the eligibility income threshold to ensure the credits "afforded to the population that they are intended to serve." Under the current bill, individuals with annual incomes up to $115,000 would be eligible for tax credits.

Anthem CEO pens support for parts of the House GOP's ACA replacement plan

The committee also voted along party lines to recommend a motion offered by:

  • Rep. Matt Gaetz (R-Fla.), which would support amendments "that do not incentivize new Medicaid enrollment";
  • Palmer, which would require work requirements for "able-bodied" beneficiaries; and
  • Rep. Todd Rokita (R-Ind.), which would give states a choice of Medicaid funding models between the GOP bill's proposed per capital allotment model and a fixed-payment, block-grant model.

Democrats reiterated their criticisms of the underlying legislation, highlighting the recent the Congressional Budget Office report that projected 14 million fewer Americans would have health coverage one year after the plan's enactment.

Democrats on the panel also proposed several recommendations, all of which were rejected along party lines, with one exception: Rep. John Faso (R-N.Y.) voted in favor of a motion to eliminate the bill's one-year defunding of Planned Parenthood. The motion did not pass.

Conservative demands

Conservative objections to the bill continued even after the committee vote. In a press conference, several members of the House Freedom Caucus said they plan to introduce an amendment to the bill that would fully repeal the ACA.

Freedom Caucus Chair Mark Meadows (R-N.C.) declined to specify the exact changes the group is seeking, but said the changes could be introduced as soon as Friday.  "We're working very diligently to try to make sure that any amendment that we put forth has a real chance of success," he said.

Meadows earlier this week said the caucus' members are prepared to vote against the bill if it reaches the House floor without substantial changes. According to Modern Healthcare, Republican leaders would not have enough votes to pass AHCA in the House if all 40 members of the Freedom Caucus and all Democrats vote against the bill.

Meanwhile, members of the conservative Republican Study Committee said they are working to add a work requirement for some Medicaid beneficiaries, and want to freeze the ACA's Medicaid expansion in 2018 rather than 2020. However, according to the Washington Times, moving up the Medicaid expansion's freeze date could be a "nonstarter" for moderate Republicans who call themselves the Tuesday Group.

Republican governors raise concerns

Some Republican governors also are opposed to the GOP's approach to Medicaid. In a letter to congressional leaders, Govs. Asa Hutchinson of Arkansas, John Kasich of Ohio, Brian Sandoval of Nevada, and Rick Snyder of Michigan wrote that the bill's current approach to Medicaid "provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states."

The governors outlined a nine-page proposal that would give states more options to change Medicaid and modifies the shift to the House bill's new Medicaid payment model.

House Speaker Paul Ryan (R-Wis.) on Thursday said, "We feel like we're making great strides and great progress on getting a bill that can pass" and that Trump has been "helping bridge gaps in our conference." However, Ryan declined to specify a timeline for when the bill could reach the House floor.

Rep. Bill Flores (R-Texas) said Republicans should aim to get the legislation passed before Congress begins its two-week spring recess next month. "That's never healthy to let something sit out there too long because pretty soon you have a carcass left," he said  (DeBonis/Sullivan, "PowerPost," Washington Post, 3/16; Golshan, Vox, 3/16; Howell, Washington Times, 3/16; Alonso-Zaldivar/Fram, AP/Washington Times, 3/17; Dickson, Modern Healthcare, 3/16; Cancryn, Politico, 3/16; Caldwell, NBC News, 3/16; Nather, "Vitals," Axios, 3/17).

Navigating the first 100 days of the Trump administration


Since Donald Trump won the presidential election in November, health care reform has since quickly risen to the top of the GOP's policy agenda—and heath care executives are grappling with a new sense of uncertainty.

While many unknowns will remain across the next few months and potentially even years, the first 100 days of the Trump administration will provide significant insight into the direction of reform efforts. Read our briefing to learn what five key issues you should watch.

Download the briefing

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