The American Health Care Act of 2017 (AHCA) was a leading proposal in the first half of 2017 by House Republicans to "repeal and replace" the Affordable Care Act (aka Obamacare, but we'll abbreviate it ACA) and "defund" Planned Parenthood. It was also the vehicle for passage of the Senate Republicans' leading proposals.

The bill was brought to the House and Senate floors under the rules of the budget reconciliation process, by which one bill each year is immune to a Senate filibuster so long as it meets certain requirements related to the budget. By being immune to a filibuster, only 51 votes were needed in the Senate rather than 60. But during Senate proceedings the bill was nevertheless ruled out of order for having provisions that were not related to the budget, forcing several votes with 60-vote thresholds.

On March 9, 2017 the text of the AHCA was first made available. It was a comprehensive plan that repealed major parts of the ACA, including the Medicaid expansion and many taxes, but also kept major parts of the ACA intact, such as the exchanges. After a fast-paced few weeks, the vote scheduled for March 24, 2017 was cancelled after the House Freedom Caucus, a band of some of the most conservative members of the House, pledged in block to oppose the AHCA because it did not go far enough to repeal the ACA. The AHCA was revised on May 4 and then passed the House the same day.

The bill then went to the Senate. On June 22, Senate Republicans released their first draft of health care reform, called the Better Care Reconciliation Act of 2017 (BCRA), which would have replace the health care bill text proposed by House Republicans if the Senate passed it. A new draft of the Senate Republican plan was made available on July 13.

On July 25 the BCRA went to the Senate floor after a passed motion to proceed but then failed. A vote on clean repeal, mirroring the 2015 repeal bill that was vetoed by President Obama, also failed. In the early hours of July 28, the Senate voted on a pared-down repeal without replacement, which also failed. More details on the Senate proposals can be found on the vote pages.

Summary of the AHCA as passed by the House

On May 4, a deal among the Republican factions lead to changes to the AHCA, as reported by the Rules committee, which were:

States may opt-out of providing the ACA’s essential health benefits. (This requirement was already dropped in the bill for Medicaid but not for the individual market.)

States may opt-out of requiring premiums to be the same for all people of the same age, so while individuals with pre-existing conditions must be offered health insurance there is no limit on the cost of that insurance. A new $8 billion fund would help lower premiums for these individuals.

States may opt-out of limiting premium differences based on age.

There would be a new $15 billion fund for risk sharing to help states lower premiums.

Our summary of the original AHCA text follows.

Summary of the AHCA as of March 9

What would stay the same

The bill would keep intact much of the ACA. As the Republican website readthebill.gop explains, the AHCA would "preserve vital patient protections" created by the ACA:

The AHCA would keep the ACA's requirement that dependents can stay "on their parents' plan until they are 26."

The exchanges (aka marketplaces) run by the federal government and states, which listed individual and small business health insurance plans, would continue as under the ACA.

The AHCA would also continue to provide subsidies for premiums that are based on income, although the formula would be completely different and the subsidy would likely be much less for young, low-income Americans.

And according to this summary from USA Today:

The AHCA would keep some Medicaid benefits for those that enroll prior to 2020 (more on that below).

The AHCA would keep the restriction that subsidies can't pay for health insurance that covers abortion.

The individual mandate stays too, but by any other name

The AHCA even includes a penalty for individuals who don't get coverage, referred to as the "individual mandate" in the ACA. While the ACA imposes a roughly $700 per year penalty for not holding health insurance, the AHCA would instead impose a surcharge of up to 30% the next time you get insurance after a lapse in coverage.

Depending on your premiums and how long you go without insurance, the ACHA's penalty could be more or less than the ACA's current penalty. In many cases, it might be about the same.

What would be expanded

Contribution limits to Health Savings Accounts (HSAs) would be increased to encourage their use. With HSAs, you can put aside some of your income for medical expenses and not pay taxes on it. (More on that here.)

Under the AHCA, federal subsidies for paying premiums could be used to pay for insurance both from and not from the exchanges.

What would go away

Some parts of the ACA would end:

If you're on Medicaid...

The ACA expanded Medicaid eligibility in 32 states that opted in to it. The AHCA would reverse the eligibility expansion beginning in 2020 (anyone enrolled by then would remain enrolled), and it would reduce federal support for Medicaid with caps on coverage.

The ACA expanded required benefits under Medicaid, such as mental health and addiction services, which would no longer be required.

If you're covered through your employer...

If you're on an individual plan...

The ACA limited what health insurance providers could charge in premiums. Under the AHCA, those limits would be adjusted so that younger people might see lower premiums and older people much higher premiums.

The ACA's complex cost-sharing provisions that lowered costs for some low-income Americans would be eliminated.

The ACA's awkward bronze/silver/platinum levels would go away.

Other changes...

A long list of taxes created by the ACA to pay for its subsidies would be eliminated, but some new taxes will be added, such as a new tax on the value of health insurance provided by an employer.

Parts of last year's last-minute bipartisan 21st Century Cures Act would be defunded.

"Defunding" Planned Parenthood

The AHCA would also prohibit federal funding from going to Planned Parenthood, mostly through Medicaid, for one year.

This would pause federal reimbursements for Planned Parenthood's reproductive health, maternal health, and child health services --- but not its abortion services because federal funds are already prohibited from being used for abortion.

What's the bottom line?

How the AHCA would affect you depends on your income, how you get your health insurance, and what kinds of health care you need.

For older, low-income Americans with health insurance from the individual market: Premiums could increase by $3,600 for a 55-year-old earning $25,000 a year and $8,400 for a 64-year-old earning $15,000 a year. AARP

For low-income Americans covered by Medicaid, the federal cap on support would likely lead to fewer benefits and higher out-of-pocket costs. AARP 5--18 million individuals are predicted to lose Medicaid coverage entirely. NYTimes

If you are covered through your employer, your employer would be allowed to stop providing coverage --- and that's made more likely because tax credits and the tax advantage for employer-provided coverage would be eliminated. But experts are split on whether the AHCA will affect employer coverage --- and even whether the ACA ever had any effect on employer coverage to begin with. NYTimes

Americans with income around $40,000-$75,000 who purchase an individual plan may be better off because the ACA's subsidies for low-income Americans would be spread out to income up to $75,000. USA Today (Unless premiums go up too.) If your income is below that, some of your subsidies are now going to go to other people with higher income.

If you have an income of $200,000 or more, or investment income, you can expect your tax bill to go down --- those making $1 million or morecan expect around $50,000 less in taxes each year.

Major changes to the health insurance market like the ACA and AHCA have far-reaching effects on federal spending and the economy. But experts polled by The New York Times are split on whether the AHCA will save the government or cost more because the AHCA lowers both government spending and tax revenue.

Odds of passage

Despite now controlling both the legislative and executive branches, and having previously voted successfully 45 times in the House to repeal the ACA, the Republicans' AHCA is not a done deal.

On the one hand, both the House Energy & Commerce and Ways and Means Committees passed their respective sections of legislation on March 9 with party line votes. On the other hand, the House Freedom Caucus, some high profile senators like Mike Lee (R-UT) and Rand Paul (R-KY), and industry groups like the American Medical Association and American Hospital Association have all spoken publicly against the legislation --- some for the reason that it does not repeal enough of Obamacare. No Democrats will likely support it. The ACA also has all-time high support from the American public, with support reaching 54 percent last month.

Usage of the budget reconciliation process

The Republicans don't have the votes to pass the AHCA the normal way. Knowing that it would be filibustered by Senate Democrats, Republicans are using the "budget reconciliation" process to move their bill forward. Budget reconciliation makes one bill each year immune to a filibuster (in the Senate), and the AHCA is this year's bill. The Democrats used budget reconciliation to enact parts of the ACA originally, so the use of reconciliation to modify the ACA (but not repeal it) is fitting.

Reconciliation can only be used on some types of bills that affect the federal budget, limiting the sorts of provisions that can be included in the AHCA --- a full repeal of the ACA wouldn't be permitted under reconciliation rules. The reconciliation process also requires the House Budget committee to formally introduce the bill after it goes through committee --- that's why the AHCA was revealed to the public on March 6 as a draft at readthebill.gop and only formally introduced as a bill in Congress on March 20.

Although there are procedural similarities between how the ACA was enacted and what is happening now with the AHCA, there are also significant differences. The ACA was enacted after vigorous debate on competing and substantive policy proposals for nearly a year, with most of the final text available for several months before it was signed by President Obama. The AHCA is on track to going from draft to law within a matter of weeks and with hearings occurring when America is asleep.

For More Information