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115th Congress, Vote 256; House of Representatives #1628

American Health Care Act of 2017

Official Title: To provide for reconciliation pursuant to title II of the concurrent resolution on the budget for fiscal year 2017.

Official Title: To provide for reconciliation pursuant to title II of the concurrent resolution on the budget for fiscal year 2017.

HR 1628: American Health Care Act of 2017 (AHCA)
Passed by House on May 4, 2017, 217-213 (1 not voting)

History: The AHCA was introduced by House Republicans on March 6, 2017 as a combination of bills drafted by the House Ways and Means Committee (text; summary) and the House Energy and Commerce Committee (text; summary).

After gaining approval in the committees, the bill was altered on March 20 by a Manager's Amendment which included technical changes (text; summary) and policy changes (text; summary)

The bill was scheduled for a full vote in the House of Representatives on March 24, but was pulled at the last minute, after hours of debate, when it was evident that there wasn't enough Republican support to pass it. (All Democrats in the House were opposed to it from the start.)

The following week, the bill was back under consideration. On April 6, an amendment (text; summary) was added to create an "invisible risk sharing program," funded with $15 billion over nine years.

On April 25, Rep. Tom MacArthur (R-New Jersey) introduced the MacArthur Amendment (text; summary) which allows states to seek waivers to alter various ACA consumer protections, including community rating, essential health benefits, and age band ratios. This amendment garnered the support of the ultra-conservative House Freedom Caucus, but moderate Republicans were concerns about the impact on people with pre-existing conditions.

On May 3 (the day before the House voted on the AHCA), Rep. Fred Upton (R-Michigan) introduced the Upton Amendment (text; summary). The amendment provides $8 billion over five years, to offset the higher "premiums or other out-of-pocket costs" that people would experience in waiver states if they have pre-existing conditions and a gap in coverage. With this amendment, House leadership was able to get just barely enough support to pass the bill.

The bill passed the House on May 4, by a vote of 217 to 213. It needed 216 votes to pass, so it was a razor-thin margin.

The bill now heads to the Senate, but the Senate has indicated that it will write its own legislation, attempting to incorporate as much of the House bill as possible.

A reconciliation bill can pass in the Senate with 51 votes, one of which can be a tie-breaker vote cast by the Vice President. There are 52 Republicans in the Senate, so if more than two of them oppose the AHCA – or the Senate's version – it will not pass.

Synopsis: Republicans in Congress have been working to repeal the ACA ever since it was signed into law in 2010. The AHCA is a reconciliation bill designed to repeal spending-related provisions of the ACA and replace some of them with Republican alternatives.

A reconciliation bill is not subject to filibuster, and can thus pass with a simple majority in the Senate. But reconciliation legislation can only address provisions that directly impact the federal budget. So full repeal of the ACA is not possible with a reconciliation bill (that could only be done with a bill that would need 60 votes in the Senate to overcome a filibuster). But the law's spending-related provisions can be repealed or changed via reconciliation.

H.R.1628 is the result of S.Con.Res.3 , which passed in January and directed Congressional committees to draft reconciliation legislation to repeal spending-related provisions of the ACA.

To be clear, the AHCA does not repeal most of the ACA:

There are other provisions of the ACA that would remain unchanged in some states, but which could be changed via waivers in states that wished to do so:
  • Community rating. In states that seek a waiver, insurers would be able to charge higher individual market premiums based on an applicant's medical history, if the applicant had a gap in coverage of at least 63 days in the previous year.
  • Essential health benefits. In states that seek a waiver, the services that are considered essential health benefits could be redefined. Since the ACA's ban on lifetime and annual benefit caps only applies to essential health benefits, as does the limitation on out-of-pocket costs, those protections would be weakened.
  • Age band ratios. The ACA limits premiums for older enrollees to three times those of younger enrollees. The AHCA allows that ratio to be 5:1, but states can seek waiver to further increase the ratio. Higher age band ratios mean higher premiums for older enrollees (age 50-64) and lower premiums for people in their 20s.
The AHCA changes or repeals the ACA's taxes/penalties, premium subsidies, cost-sharing subsidies, and Medicaid expansion. In summary:
  • The individual mandate penalty and employer mandate penalty would be eliminated, retroactively to the beginning of 2016.
  • The Cadillac tax, currently scheduled to take effect in 2020, would be postponed until 2026.
  • Various other ACA taxes are repealed, including the 3.8 percent capital gains tax and the 0.9 percent Medicare tax on high-income filers, the tanning bed tax, the taxes on health insurers and pharmaceutical manufacturers, and the medical device tax.
  • ACA premium tax credits would be modified in 2018/2019 (increased for younger people, decreased for older people, and made available for off-exchange plans and catastrophic plans)
  • ACA tax credits would be replaced as of 2020. The new tax credits would be available in full to people with income up to $75,000 ($150,000 for a married couple) and would be phased out for incomes above that level. Otherwise, the tax credits would only vary based on age. They would not be larger for lower-income people or for people in areas where health insurance is more expensive (as is the case with ACA tax credits). Overall, the tax credits would be smaller than the ACA's tax credits, although people with income above 400 percent of the poverty level - who do not receive any premium tax credits under the ACA - would be eligible to receive them. This interactive map shows how they would work.
  • After the 2018 open enrollment period (November 1, 2017 to December 15, 2017), people who enroll in individual market plans following a gap in coverage of at least 63 days within the previous 12 months would be subject to a 30 percent premium increase for the duration of the plan year. Alternatively, states could opt for a waiver that would allow for higher premiums based on medical underwriting (ie, they would only apply to people with pre-existing conditions) for people who had experienced a gap in coverage.
  • The AHCA provides $100 billion over 9 years for a Patient and State Stability Fund, $15 billion over nine years for an "invisible risk sharing program" and $8 billion over five years to offset the higher premiums people with pre-existing conditions would pay in states that allow medical underwriting for people with a gap in coverage.
  • Federal funding for Planned Parenthood would be prohibited for one year.
  • States that choose to expand Medicaid after March 1, 2017 would only be able to get their regular federal Medicaid funding match; they would not be eligible for the 95 percent federal funding that they would have received (from 2017 through 2019) under the ACA, or the 90 percent federal funding thereafter.
  • In states that have already expanded Medicaid, ACA Medicaid expansion funding would continue (along with continued enrollment) through the end of 2019. After that, no new enrollments at the higher federal match would be allowed, and people already enrolled would only continue to be funded at the ACA level if they remained continuously enrolled.
  • Federal Medicaid funding would be converted to a per-capita allotment as of 2020. States would also have the option to receive a block grant for their non-expansion population.
  • HSA contribution limits would be increased, as of 2018, to equal the maximum allowable out-of-pocket exposure on HSA-qualified plans (that amount is indexed for inflation; in 2017, it's $6,550 for individual coverage and $13,100 for family coverage).

Why supporters pushed for this bill

  • Republican lawmakers have wanted to repeal the ACA for seven years. Many current Republicans in Congress campaigned on a promise to repeal the ACA, and H.R.1628 gives them an opportunity to make good on that promise, to some degree.
  • Although the legislation only repeals some parts of the ACA, it repeals the parts that are most hated by conservatives: the individual and employer mandate penalties, and the law's various taxes. It also changes Medicaid to reduce federal spending, which tends to appeal to conservatives.
  • The CBO projects that the AHCA would lower the federal deficits by $337 billion over the next decade.

Why opponents tried to stop the bill

  • Democrats have long supported the ACA, and continue to reiterate the many ways that it's helping Americans, including the fact that the uninsured rate is at an all-time low .
  • Some conservative Republicans are opposed to the AHCA because they feel that it doesn't go far enough in terms of repealing the ACA.
  • The Congressional Budget Office scored the AHCA on March 13 (prior to the Manager's Amendment and any changes that were made late in the day on March 22). At that point their projection was the the uninsured population would increase by 24 million people over the next decade if the AHCA were to be implemented. Their score after accounting for the Manager's Amendment still projected 24 million fewer people with health insurance.
  • The CBO had not yet scored the later amendments by the time the House voted to pass the AHCA. As such, lawmakers were voting on a bill without a clear understanding of its impact.
  • There are concerns that the AHCA could destabilize the individual health insurance market for 2018. If the individual mandate is repealed retroactive to 2016, the CBO predicts that 4 million people would drop their coverage in mid-2017. Half of them are in the individual market, which would result in a sicker risk pool and claims costs being spread across a smaller insured population. The result could be more insurer exits from the individual market at the end of 2017. The CBO also predicts that premiums will rise by 15 to 20 percent in 2018 and 2019 if the AHCA is enacted.
  • The premium tax credits will extend further into the middle-class and upper-middle-class under the AHCA, but that will come at the expense of older and lower-income Americans.
  • Ending new Medicaid expansion enrollments after 2019 and converting federal Medicaid funding to a per-capita allotment would save the government money, but it would result in a lot of low-income people becoming uninsured. The CBO projects that 14 million fewer people would be enrolled in Medicaid by 2024 if the AHCA is enacted. Given the relatively small size of the AHCA tax credits, it's unlikely that many people who lose Medicaid will be able to purchase other coverage as a replacement.
  • Essentially, the AHCA provides a large tax break to the wealthiest Americans, while making health insurance unaffordable for people with low incomes and people over the age of 50 with low or modest incomes.
05/04/2017 Status: House passed

More: select a member to see his or her other key health care votes.

Yes (217)
R Don Young AK
R Robert Aderholt AL
R Mo Brooks AL
R Bradley Byrne AL
R Gary Palmer AL
R Martha Roby AL
R Mike Rogers AL
R Eric Crawford AR
R French Hill AR
R Bruce Westerman AR
R Steve Womack AR
R Trent Franks AZ
R Paul Gosar AZ
R Martha McSally AZ
R David Schweikert AZ
R Ken Calvert CA
R Paul Cook CA
R Jeff Denham CA
R Duncan Hunter CA
R Darrell Issa CA
R Steve Knight CA
R Doug LaMalfa CA
R Kevin McCarthy CA
R Tom McClintock CA
R Devin Nunes CA
R Dana Rohrabacher CA
R Edward Royce CA
R David Valadao CA
R Mimi Walters CA
R Ken Buck CO
R Doug Lamborn CO
R Scott Tipton CO
R Gus Bilirakis FL
R Vern Buchanan FL
R Carlos Curbelo FL
R Ron DeSantis FL
R Mario Diaz-Balart FL
R Neal Dunn FL
R Matt Gaetz FL
R Brian Mast FL
R Bill Posey FL
R Francis Rooney FL
R Thomas Rooney FL
R Dennis Ross FL
R John Rutherford FL
R Daniel Webster FL
R Ted Yoho FL
R Rick Allen GA
R Buddy Carter GA
R Doug Collins GA
R A. Ferguson GA
R Tom Graves GA
R Jody Hice GA
R Barry Loudermilk GA
R Austin Scott GA
R Rob Woodall GA
R Rod Blum IA
R Steve King IA
R David Young IA
R Raúl Labrador ID
R Michael Simpson ID
R Mike Bost IL
R Rodney Davis IL
R Randy Hultgren IL
R Adam Kinzinger IL
R Darin LaHood IL
R Peter Roskam IL
R John Shimkus IL
R Jim Banks IN
R Susan Brooks IN
R Larry Bucshon IN
R Trey Hollingsworth IN
R Luke Messer IN
R Todd Rokita IN
R Jackie Walorski IN
R Ron Estes KS
R Lynn Jenkins KS
R Roger Marshall KS
R Kevin Yoder KS
R Garland Barr KY
R James Comer KY
R Brett Guthrie KY
R Harold Rogers KY
R Ralph Abraham LA
R Garret Graves LA
R Clay Higgins LA
R Mike Johnson LA
R Steve Scalise LA
R Andy Harris MD
R Bruce Poliquin ME
R Justin Amash MI
R Jack Bergman MI
R Mike Bishop MI
R Bill Huizenga MI
R Paul Mitchell MI
R John Moolenaar MI
R Dave Trott MI
R Fred Upton MI
R Tim Walberg MI
R Tom Emmer MN
R Jason Lewis MN
R Erik Paulsen MN
R Sam Graves MO
R Vicky Hartzler MO
R Billy Long MO
R Blaine Luetkemeyer MO
R Jason Smith MO
R Ann Wagner MO
R Gregg Harper MS
R Trent Kelly MS
R Steven Palazzo MS
R Ted Budd NC
R Virginia Foxx NC
R George Holding NC
R Richard Hudson NC
R Patrick McHenry NC
R Mark Meadows NC
R Robert Pittenger NC
R David Rouzer NC
R Mark Walker NC
R Kevin Cramer ND
R Don Bacon NE
R Jeff Fortenberry NE
R Adrian Smith NE
R Rodney Frelinghuysen NJ
R Tom MacArthur NJ
R Stevan Pearce NM
R Mark Amodei NV
R Chris Collins NY
R John Faso NY
R Peter King NY
R Tom Reed NY
R Elise Stefanik NY
R Claudia Tenney NY
R Lee Zeldin NY
R Steve Chabot OH
R Warren Davidson OH
R Bob Gibbs OH
R Bill Johnson OH
R Jim Jordan OH
R Robert Latta OH
R James Renacci OH
R Steve Stivers OH
R Patrick Tiberi OH
R Brad Wenstrup OH
R Jim Bridenstine OK
R Tom Cole OK
R Frank Lucas OK
R Markwayne Mullin OK
R Steve Russell OK
R Greg Walden OR
R Lou Barletta PA
R Mike Kelly PA
R Tom Marino PA
R Tim Murphy PA
R Scott Perry PA
R Keith Rothfus PA
R Bill Shuster PA
R Lloyd Smucker PA
R Glenn Thompson PA
R Jeff Duncan SC
R Trey Gowdy SC
R Tom Rice SC
R Marshall Sanford SC
R Joe Wilson SC
R Kristi Noem SD
R Diane Black TN
R Marsha Blackburn TN
R Scott DesJarlais TN
R John Duncan TN
R Charles Fleischmann TN
R David Kustoff TN
R David Roe TN
R Jodey Arrington TX
R Brian Babin TX
R Joe Barton TX
R Kevin Brady TX
R Michael Burgess TX
R John Carter TX
R K. Conaway TX
R John Culberson TX
R Blake Farenthold TX
R Bill Flores TX
R Louie Gohmert TX
R Kay Granger TX
R Jeb Hensarling TX
R Sam Johnson TX
R Kenny Marchant TX
R Michael McCaul TX
R Pete Olson TX
R Ted Poe TX
R John Ratcliffe TX
R Pete Sessions TX
R Lamar Smith TX
R Mac Thornberry TX
R Randy Weber TX
R Roger Williams TX
R Rob Bishop UT
R Jason Chaffetz UT
R Mia Love UT
R Chris Stewart UT
R David Brat VA
R Thomas Garrett VA
R Bob Goodlatte VA
R H. Griffith VA
R Scott Taylor VA
R Robert Wittman VA
R C. McMorris Rodgers WA
R Sean Duffy WI
R Mike Gallagher WI
R Glenn Grothman WI
R Paul Ryan WI
R F. Sensenbrenner WI
R Evan Jenkins WV
R David McKinley WV
R Alex Mooney WV
R Liz Cheney WY
No (213)
Our pick
D Terri Sewell AL
R Andy Biggs AZ
D Ruben Gallego AZ
D Raúl Grijalva AZ
D Tom O’Halleran AZ
D Kyrsten Sinema AZ
D Pete Aguilar CA
D Nanette Barragán CA
D Karen Bass CA
D Ami Bera CA
D Julia Brownley CA
D Salud Carbajal CA
D Tony Cárdenas CA
D Judy Chu CA
D J. Correa CA
D Jim Costa CA
D Susan Davis CA
D Mark DeSaulnier CA
D Anna Eshoo CA
D John Garamendi CA
D Jared Huffman CA
D Ro Khanna CA
D Barbara Lee CA
D Ted Lieu CA
D Zoe Lofgren CA
D Alan Lowenthal CA
D Doris Matsui CA
D Jerry McNerney CA
D Grace Napolitano CA
D Jimmy Panetta CA
D Nancy Pelosi CA
D Scott Peters CA
D L. Roybal-Allard CA
D Raul Ruiz CA
D Linda Sánchez CA
D Adam Schiff CA
D Brad Sherman CA
D Jackie Speier CA
D Eric Swalwell CA
D Mark Takano CA
D Mike Thompson CA
D Norma Torres CA
D Juan Vargas CA
D Maxine Waters CA
R Mike Coffman CO
D Diana DeGette CO
D Ed Perlmutter CO
D Jared Polis CO
D Joe Courtney CT
D Rosa DeLauro CT
D Elizabeth Esty CT
D James Himes CT
D John Larson CT
D Lisa Blunt Rochester DE
D Kathy Castor FL
D Charlie Crist FL
D Val Demings FL
D Theodore Deutch FL
D Lois Frankel FL
D Alcee Hastings FL
D Al Lawson FL
D Stephanie Murphy FL
R Ileana Ros-Lehtinen FL
D Darren Soto FL
D D. Wasserman Schultz FL
D Frederica Wilson FL
D Sanford Bishop GA
D Henry Johnson GA
D John Lewis GA
D David Scott GA
D Tulsi Gabbard HI
D Colleen Hanabusa HI
D David Loebsack IA
D Cheri Bustos IL
D Danny Davis IL
D Bill Foster IL
D Luis Gutiérrez IL
D Robin Kelly IL
D Raja Krishnamoorthi IL
D Daniel Lipinski IL
D Mike Quigley IL
D Bobby Rush IL
D Janice Schakowsky IL
D Bradley Schneider IL
D André Carson IN
D Peter Visclosky IN
R Thomas Massie KY
D John Yarmuth KY
D Cedric Richmond LA
D Michael Capuano MA
D Katherine Clark MA
D William Keating MA
D Joseph Kennedy MA
D Stephen Lynch MA
D James McGovern MA
D Seth Moulton MA
D Richard Neal MA
D Niki Tsongas MA
D Anthony Brown MD
D Elijah Cummings MD
D John Delaney MD
D Steny Hoyer MD
D Jamie Raskin MD
D C. Ruppersberger MD
D John Sarbanes MD
D Chellie Pingree ME
D John Conyers MI
D Debbie Dingell MI
D Daniel Kildee MI
D Brenda Lawrence MI
D Sander Levin MI
D Keith Ellison MN
D Betty McCollum MN
D Richard Nolan MN
D Collin Peterson MN
D Timothy Walz MN
D Wm. Clay MO
D Emanuel Cleaver MO
D Bennie Thompson MS
D Alma Adams NC
D George Butterfield NC
R Walter Jones NC
D David Price NC
D Ann Kuster NH
D Carol Shea-Porter NH
D Josh Gottheimer NJ
R Leonard Lance NJ
R Frank LoBiondo NJ
D Donald Norcross NJ
D Frank Pallone NJ
D Bill Pascrell NJ
D Donald Payne NJ
D Albio Sires NJ
R Christopher Smith NJ
D B. Watson Coleman NJ
D Ben Luján NM
D M. Lujan Grisham NM
D Ruben Kihuen NV
D Jacky Rosen NV
D Dina Titus NV
D Yvette Clarke NY
D Joseph Crowley NY
R Daniel Donovan NY
D Eliot Engel NY
D Adriano Espaillat NY
D Brian Higgins NY
D Hakeem Jeffries NY
R John Katko NY
D Nita Lowey NY
D Carolyn Maloney NY
D Sean Maloney NY
D Gregory Meeks NY
D Grace Meng NY
D Jerrold Nadler NY
D Kathleen Rice NY
D José Serrano NY
D Louise Slaughter NY
D Thomas Suozzi NY
D Paul Tonko NY
D Nydia Velázquez NY
D Joyce Beatty OH
D Marcia Fudge OH
R David Joyce OH
D Marcy Kaptur OH
D Tim Ryan OH
R Michael Turner OH
D Earl Blumenauer OR
D Suzanne Bonamici OR
D Peter DeFazio OR
D Kurt Schrader OR
D Brendan Boyle PA
D Robert Brady PA
D Matthew Cartwright PA
R Ryan Costello PA
R Charles Dent PA
D Michael Doyle PA
D Dwight Evans PA
R Brian Fitzpatrick PA
R Patrick Meehan PA
D David Cicilline RI
D James Langevin RI
D James Clyburn SC
D Steve Cohen TN
D Jim Cooper TN
D Joaquin Castro TX
D Henry Cuellar TX
D Lloyd Doggett TX
D Vicente Gonzalez TX
D Al Green TX
D Gene Green TX
R Will Hurd TX
D Sheila Jackson Lee TX
D Eddie Johnson TX
D Beto O’Rourke TX
D Marc Veasey TX
D Filemon Vela TX
D Donald Beyer VA
R Barbara Comstock VA
D Gerald Connolly VA
D A. McEachin VA
D Robert Scott VA
D Peter Welch VT
D Suzan DelBene WA
D Denny Heck WA
R J. Herrera Beutler WA
D Pramila Jayapal WA
D Derek Kilmer WA
D Rick Larsen WA
R David Reichert WA
D Adam Smith WA
D Ron Kind WI
D Gwen Moore WI
D Mark Pocan WI
Not Voting (1)
R Dan Newhouse WA