Programming Note: Given the potential impact and volume of activity related to ACA legislative discussions, we will be sending out a weekly update summarizing relevant developments each Thursday afternoon. This will be in addition to the regular Monday morning update, which will continue to cover a broad array of health care topics.  

ACA Repeal and Replacement Update – January 12, 2017

Republican leaders promised they would pass a budget resolution this week aimed at putting the repeal of President Barack Obama’s health care law on a fast track. But a growing number of Republican lawmakers expressed unease with the plan on January 10, seeking either a delay of the vote in the House or an amendment in the Senate that would give Congress more time to write repeal legislation. As debate on repeal and replace of the Affordable Care Act (ACA) continued, Senate Democrats and Republicans held a “vote-a-rama” to vote on various amendments introduced. Though a number of Congressional Republicans have requested a delay, the budget resolution is headed for adoption after passing in the Senate and a vote expected on January 13.

A fresh admonition from President-elect Donald Trump to pass a replacement plan “very quickly or simultaneously” with repeal added to the confusion over how long Republicans have to craft an alternative. President-elect Trump also stated in his first news conference since the election that he and his incoming Secretary will be putting forth a repeal and replacement strategy “almost simultaneously”.

Senate Action

On January 9, the Senate resumed debate on the budget resolution with almost 190 amendments introduced. Senate Democrats held the floor late into the night proposing amendments aimed at saving the ACA. Democrats made their first direct challenge with Sen. Hirono (D-Hawaii) offering an amendment aimed at preventing any cuts to Medicare or Medicaid as part of a repeal bill. The measure was defeated on a 49-47 procedural vote; 60 votes were required.

Fiscal conservatives have also been concerned with this budget measure that uses current spending and revenue projections, predicting an increase in debt of $9.7 trillion. Sen. Paul (R-KY) pushed for his own amendment that promised to balance the budget within five years. His amendment would eliminate annual deficits by freezing overall spending levels for the whole budget except for Social Security and the U.S. Postal Service. But Democrats said Paul’s plan would require massive cuts to social programs, including Medicare and Medicaid. Paul’s amendment was defeated on a 14-83 vote.

Sens. Corker (R-TN), Portman (R-OH), Collins (R-ME), Cassidy (R-LA), and Murkowski (R-AK) filed an amendment aimed at slowing down the repeal process. The current resolution instructs the Senate Finance Committee, Senate HELP Committee, House Ways & Means Committee, and House Energy & Commerce Committee to produce reconciliation legislation by January 27. The proposed amendment would push this deadline back to March 3. The five Republican Senators are part of a growing group that are calling for a replacement plan before voting on repeal, though they later withdrew the amendment stating promises from Republican leaders that January 27 was just a placeholder.

Chairman of the Health, Education, Labor and Pensions (HELP) Committee, Sen. Alexander (R-TN) laid out a plan for repeal and replace on January 10. His plan would repeal and replace the ACA simultaneously,  arguing that the ACA should only be repealed when there are concrete reforms in place that give Americans access to affordable healthcare. The plan comes in 3 steps. First, it allows Americans to continue to buy insurance on the exchanges with some flexibility in “repairing the healthcare market” while Congress and the President build a set of practical alternatives by March 1. Second, Congress will build a set of systems that will provide low cost insurance by moving regulation to the state level and removing “harmful taxes”. Third, when the reforms become concrete, practical alternatives, Congress will repeal the remaining parts of the ACA. Press Release:

On January 11 and late into the night, a “vote-a-rama” ensued with the Senate voting on 24 of the almost 190 amendments introduced on the Senate floor, and failing to pass any of them with many of the votes falling along party lines. Many of the amendments sought to create points of order against legislation that would result in reduced health insurance access, financially harm rural hospitals and health care provides by reducing the number of people with access to insurance, that would discriminate against women, that would reduce federal funding to states under Medicaid expansion, or that would increase drug prices. Several Republicans offered amendments that sought to strengthen Medicare, reform Medicaid, and repeal and replace the ACA with patient-centered health reforms that increase competition, provide state flexibility and individual choice.

The Senate approved by a vote of 51-48 the 2017 Budget Resolution, which includes reconciliation instructions for the Senate Finance Committee, Senate HELP Committee, House Energy & Commerce Committee and House Ways & Means Committee to produce legislation that achieves at least $1 billion each in deficit reduction over 10 years by January 27. Sen. Paul (R-KY) was the only Republican to vote against the resolution, noting that it was not a balanced budget.

House Action

A number of House Democrats as well as Republicans also expressed their concerns this week on the budgetary impacts of the resolution. On January 9, top Democrats, Rep. Yarmouth (D-KY) and Rep. Neal (D-MA), on the House Budget Committee and House Ways and Means Committee wrote a letter to Obama’s budget office asking for an analysis on the budget measure’s impact on the country’s long-term fiscal health. Letter:

Members of the conservative House Freedom Caucus expressed their concerns this week by requesting a delay in floor vote on the resolution until members have more details on how the GOP will structure and pass its own replacement bill, though many of them would likely still vote in favor of the resolution.

On January 10, as House Republicans began to grow more uneasy about GOP efforts to repeal the ACA without an explicit replacement strategy, Speaker Ryan suggested that some replacement language may be present in the reconciliation bill. One option being considered is to expand the use of health savings accounts and allow states to set up high-risk pools for chronically sick patients. Republicans are planning to take up less controversial replacement bills as soon as repeal passes and are discussing an effort to unite the party around a set of health care principles before the repeal vote. House Republican Conference Chairwoman McMorris Rodgers (R-WA) also stated on January 10 that “No one who has coverage today because of Obamacare will lose that coverage”.

On January 11, while he did not go into detail on the topic, Chairman of the House Ways and Means Committee, Rep. Brady (R-TX) stated that the House tax writing panel is looking to hold a hearing on the ACA this year.

The House is expected to vote on the resolution on January 13, and it will likely be approved.