With the vote Thursday, Republicans recovered from their earlier failures and moved a step closer to delivering their promise to reshape American health care without mandated insurance coverage.
The vote, 217-to-213, on President Trump’s 105th day in office, keeps alive the Republican dream of unwinding the signature legislative achievement of former President Barack Obama. The House measure faces profound uncertainty in the Senate, where the legislation’s steep spending cuts will almost certainly be moderated. Any legislation that can get through the Senate will again have to clear the House and its conservative majority.
A White House victory lap
President Trump on Thursday declared victory in his push to repeal the Affordable Care Act and overhaul the nation’s health system without mandated coverage, saying the plan would bring down costs for Americans.
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“Yes, premiums will be coming down; yes, deductibles will be coming down, but very importantly, it is a great plan,” Mr. Trump said in White House Rose Garden, flanked by Republican lawmakers. It was the kind of exuberant event typically reserved for legislation that is being signed into law, rather than a controversial bill that has narrowly passed one chamber and faces an uncertain future in the Senate.
But Mr. Trump was eager to savor the moment. Just over a month ago, he suffered a humiliating defeat on the health care plan when House leaders were forced to abruptly cancel a planned vote on the legislation because of opposition from within their own ranks, even after a burst of personal lobbying from the president.
“We want to brag about the plan,” Mr. Trump said, after asking those assembled how he was doing in his debut as a politician. “Hey, I’m president!”
Still, the victory was likely to be a fleeting one; the measure in its current form has little chance of advancement in the Senate, where its steep Medicaid cuts and provisions to scale back health benefits are being met with skepticism from members of both parties.
“We’re going to get this finished,” Mr. Trump said, before moving on to “the biggest tax cut in our nation’s history.”
“We’re going to have a tremendous eight years,” he proclaimed.
What comes next?
Despite the passage of the bill in the House, the Affordable Care Act will remain in place — at least for now.
The repeal bill is not likely to be met with great celebration in the Senate.
Yes, Republican senators share their House colleagues’ desire to repeal major parts of the Obama-era health law.
But they may not agree on exactly which parts.
Already, Republicans in the Senate have aired a variety of concerns about the House plan, including how it would affect states that expanded Medicaid under the health law and whether it would raise premiums to unaffordable levels for older Americans.
Senator Lamar Alexander of Tennessee, chairman of the Senate Health Committee, made it clear his chamber would take its time. “The Senate will now finish work on our bill, but will take the time to get it right,” he wrote.
In other words, expect to see plenty of changes to the House bill — and, in the long run, plenty more fits and starts.
A self-fulfilling prophecy
The president may make sure the Affordable Care Act collapses — and he’s got the power to do it.
Even as he boasted of the benefits the Republican health care plan will have for Americans, Mr. Trump on Thursday again raised the specter that his administration might not continue providing subsidies that are paid to insurance companies so they can reduce deductibles and other out-of-pocket costs for millions of low-income consumers.
“It’s obvious that it’s failing — it’s dead,” Mr. Trump said of the Affordable Care Act. “If we don’t pay lots of ransom money over the insurance companies, it would die immediately.”
The Trump administration had initially suggested to Democrats that it would do just that, part of an effort to force them to the negotiating table to bargain with him. But in talks last week on a spending package to fund the government through September, White House officials committed to continuing the subsidies.
On Tuesday, the White House indicated that that position could soon change; Mick Mulvaney, Mr. Trump’s budget director, said no decisions have been made beyond the month of May.
|Nancy Pelosi, the House minority leader, spoke at a rally outside the Capitol on Thursday. Credit Gabriella Demczuk for The New York Times|
House Republicans pass bill to replace and repeal Obamacare
In a major victory for President Donald Trump, the House has voted to dismantle the pillars of the Affordable Care Act and make sweeping changes to the nation's health care system.
The bill now heads to the Senate where it faces daunting challenges because of the same ideological splits between conservative and moderate Republicans that nearly killed it in the House.
Trump said he is confident the bill will pass the Senate, calling Obamacare "essentially dead."
"This is a great plan. I actually think it will get even better. This is a repeal and replace of Obamacare. Make no mistake about it," Trump said at a celebratory White House appearance with House Republicans.
After a dramatic week of negotiations, lobbying from Trump and Republican leaders, the vote ended with 217 GOP lawmakers backing the measure. Twenty Republicans opposed it, as did all House Democrats.
Trump argued the health care process has unified the GOP. "We've developed a bond," he said. "This has really brought the Republican Party together."
"As far as I'm concerned, your premiums are going to come down," Trump said.
Democrats were unable to stop the GOP vote aimed at President Barack Obama's signature legislative achievement. But after the final vote was cast, they chanted "nah nah nah nah hey hey hey goodbye" to their Republican colleagues, with a few members waving, as they believe the vote will lead to many GOP lawmakers losing their seats in the November 2018 midterms.
Thursday marks a political milestone -- one that has painfully eluded Trump and House leaders for months. The controversial health care bill delivered Trump the biggest political defeat of his short presidency in March, when the legislation had to be yanked from the House floor because it simply didn't have enough support.
Under pressure from an antsy Trump looking to score a big political victory, Republican leaders tried again last week, hoping to to get to 216 votes ahead of the President's symbolically important 100-day mark in office. That effort, too, failed.
Before the vote on the House floor, House Speaker Paul Ryan made the case that Republicans had no choice but to work to put Obamacare -- what he called a "failing law" -- behind them. "Let's give people more choices and more control over their care."
"Let's return power from Washington to the states," Ryan said.
"A lot of us have been waiting seven years to cast this vote." Ryan said. Many lawmakers, he added are "here because they promised to cast this vote."
'Rocky' plays in GOP meeting
Thursday morning, Republicans were already in a celebratory mode. The theme song to "Rocky" played as members filed in to a meeting in the House basement.
Rep. Daniel Webster described Ryan as almost "giddy."
Asked if he will be relieved when all of this is over, Virginia Rep. Dave Brat said simply: "Highly!"
When it came time for House Majority Leader Kevin McCarthy to speak in the meeting, an image of Gen. George S. Patton popped up on the LCD screens in the room. McCarthy proceeded to roll off several motivational quotes from Patton to urge the conference along.
There was also high praise for Trump: New York Rep. Chris Collins credited the President for getting the bill across the finish line. "This was Donald J. Trump, the negotiator getting it done," Collins said.
Before the final vote, the House unanimously passed a separate bill that will ensure members of Congress and their staffs are subject to the rules of their new health care measure. Originally, Republicans were under fire after it was reported that they wouldn't be subject to the rules of their own bill. Republicans said that they were required to include the exemption under Senate rules.
Democrats ready for 2018 fight
Democrats, for their part, are poised to hold the health care bill over the heads of Republicans next year.
As anxious reporters stood outside of Ryan's office Wednesday night, waiting for guidance on whether there would be a vote Thursday morning, Democratic Rep. Elijah Cummings approached the group to joke that he had a "breaking" announcement.
Republicans had the votes on their health care bill, Cummings said. His punchline: And Democrats will take back the House in 2018.
As originally introduced, the GOP bill would leave 24 million fewer people insured by 2026 than under Obamacare, the non-partisan Congressional Budget Office said. There will not be a new CBO report before Thursday's vote on the legislation.
House Minority Leader Nancy Pelosi blasted the bill and timing of the vote.
"Do you believe in what is in this bill?" she said Thursday. "Some of you have said ... well, they'll fix it in the Senate. But you have every provision of this bill tattoos on your forehead you will glow in the dark on this one."
The remark was met with cheers and applause.
"You will glow in the dark," she repeated. "So don't walk the plank."
But the weight of the moment -- Republicans being able to start the process of replacing Obamacare -- was not lost on Democrats.
Off of the House floor, Democratic Rep. Emanuel Cleaver raised his left pant leg to show a CNN reporter huge scars he has on his knee. He said he has had six surgeries, two to replace his knee.
"I'm thinking about the people back home who are hurting. I'm talking about myself. I mean, I'm a pre-existing condition," he said. "It's not apolitical game for all these people out here in the country who are hurting and scared to death."
Cleaver said when Obamacare was enacted in 2010, he never could have imagined that this day would come.
"I thought that even though this place has become toxic, that nobody would jeopardize the health of millions of people for some political purpose," he said. "And the number is still 24 million people who will be without health coverage."
What's in the bill?
The GOP health care bill would eliminate Obamacare taxes on the wealthy, insurers and others, and get rid of the individual mandate imposed by Obamacare, officially known as the Affordable Care Act. Instead of the Obamacare subsidies that are tied to income and premiums, the GOP plan would provide Americans with refundable tax credits based mainly on age to purchase health insurance.
The legislation would also allow insurers to charge higher premiums to those in their 50s and early 60s, compared to younger consumers.
It would also significantly curtail federal support for Medicaid and allow states to require able-bodied adults to work. After 2020, states that expanded Medicaid would no longer receive enhanced federal funding to cover low-income adults, and those that hadn't expanded would be immediately barred from doing so.
And it would allow states to relax some key Obamacare protections of those with pre-existing conditions, which are among the health reform law's most popular provisions. States could apply for waivers to allow insurers to offer skimpier policies that don't cover the 10 essential health benefits mandated by Obamacare. Also, insurers would be able to charge higher premiums to those with medical issues if they let their coverage lapse. States requesting waivers would have to set up programs -- such as high-risk pools -- to protect insurers from high-cost patients.
An eleventh-hour amendment that helped seal the missing GOP votes would add $8 billion over five years to fund high-risk pools and go toward patients with pre-existing conditions in states that seek waivers under the Republican legislation. The legislation already included $130 billion in the fund.
However, the GOP bill doesn't touch one beloved piece of Obamacare -- letting children stay on their parents' insurance plans until the age of 26.
How Don Young went from 'no' to 'yes' on the House health care bill
WASHINGTON — Alaska Rep. Don Young voted "yes" on Republicans' bill to repeal and revise parts of the Affordable Care Act Thursday, saying he had negotiated assurances of future changes and had faith in the legislative process that lies ahead.
Young's vote in favor of the American Health Care Act was a change from his previous position on the bill before it was pulled from the House floor in March. Young said then he wouldn't vote for the bill because of the outsize impact it would have on Alaskans' health care costs.
In the days since the House returned from a two-week recess, Young had been mum about his plans for the vote, frequently showing up as "undecided" on Capitol Hill reporters' vote-count lists. He said that was because he was still negotiating.
"I wanted a pause from the first bill that was introduced. I thought it was too fast," Young said.
But Alaska's sole member of the House of Representatives has new confidence in the bill and its future. Now that there has been more time for negotiations, he said, he's ready to give over to the legislative process.
"This bill we passed today will not become law. It'll be changed as time goes by. But unless we move it, or move a vehicle, nothing's going to happen, and that's not good," Young said Thursday in an interview after the vote.
The full extent of the bill's impacts remains unclear, as the nonpartisan Congressional Budget Office has not had a chance to release a "score" on the expected costs and effects of the law. Alaska may be among the hardest hit.
"I got a commitment from the Speaker to take care of the disproportionate cost — we and Illinois are really hurt the worst, but we think we can take care of that," Young said.
"And I know we have the money, about $19 billion that can be dispersed" to offset costs, he said. "I've talked to the Secretary (of Health and Human Services) — Dr. (Tom) Price — and he assures me that (Alaska) will be made whole, if it was to become law."
Alaska Gov. Bill Walker said Thursday that the House bill "could be a game-changer for Alaska. Our state would be the most negatively affected if the proposed legislation is signed into law as is. Alaskans already pay the highest health care premiums in the country."
Walker pointed to Alaska's opioid epidemic, and said that affordable health insurance coverage is "critical to provide necessary treatment" to addicts. "My team and I will continue working with members of our Congressional Delegation to ensure Alaskans are protected and covered," Walker said.
Differences from Obamacare
Recent amendments to the new plan included one that created a new, $15 billion risk-sharing program for states to lower coverage costs in the individual markets, and another $8 billion fund to cut into higher costs some people will pay in states that have done away with a requirement that insurers cover people with pre-existing conditions, but are helping them obtain insurance through "high risk pools."
The new plan would repeal the mandate for U.S. citizens to have health insurance, the requirements placed on health care plans, and by 2020, the subsidies that limit costs for many customers who get their plans through through the health care exchange. The bill bases the criteria for health care subsidies on age and income, eliminating considerations for geography and health care costs.
Changes to the bill will allow states to opt out of restrictions that keep insurance companies from charging people more if they have "pre-existing" conditions. The range of pre-existing conditions is wide-ranging, from asthma, to cancer, to having undergone a cesarean section or, in some cases, treatment for sexual assault. About 25 percent of Americans have a pre-existing condition, according to the Kaiser Family Foundation.
The bill will also place limits on federal funding for Medicaid. Alaska expanded its Medicaid program under the deal offered by the Affordable Care Act, often referred to as Obamacare.
"Once you get the toothpaste out of the tube, you can't put it back in," Young said of the Affordable Care Act. "But you can improve upon it. And that's what we should do. Does this do the full job? No. But it's the beginning of the process."
The biggest impact to Alaska from the prior version of the bill could come in its cost. The state has far higher insurance costs than most states, and the House plan does not offer the same subsidies as the Affordable Care Act.
According to the Center for Budget and Policy Priorities, Young's negotiations and the Senate changes to the bill would have to manage quite a bit to make up for Alaska's disproportionately poor showing under the House bill. The state has far higher insurance costs than most states, and the House plan does not offer the same subsidies as the Affordable Care Act.
The lower tax credits and increased costs under the House bill would increase yearly costs for people on Alaska's health care exchange by $12,599. The bill wouldn't keep pace with Medicaid growth, and would end subsidies that cover out-of-pocket costs for Alaska Natives in the marketplace, according to CBPP.
Nationwide, about 1 in 10 non-elderly people would lose health insurance under the House bill, a ratio that could be even higher for Alaska, according to the CBPP.
And CBPP says that Alaska's state lawmakers would face enormous pressure to waive requirements for covering people with pre-existing conditions, "since Alaska's individual market would suffer perhaps the most severe shock of any state's under the House bill," with "a nine-fold increase in the premiums for marketplace consumers, on average."
Young said that it was his responsibility to move the bill forward, even though he didn't think it was perfect.
"I had nothing but total complaints about Obamacare, especially from young people," during the 2016 election, he said.
The Senate's turn
On Wednesday afternoon, before House leadership called for Thursday's vote, Alaska Republican Sen. Lisa Murkowski raised concerns about the expedited path the House was taking, and how the bill was shaking out.
"What I have seen that causes me a little worry is the reports that well, okay, we put this fund over here – it was a $15 billion fund. And now we're going to put this fund over here, and it's going to be an $8 billion fund… Well, you remember with the Affordable Care Act, the Republicans were very, very critical of what we consider these slush funds for preventative care," she said.
Murkowski also said she's firmly opposed to removing protections for people who have pre-existing conditions.
"That's not what Alaskans are telling me they think is an acceptable response," she said.
Murkowski said she fears the House "is basically trying to just build the votes rather than build good policy," and get the "monkey off its back" to pass the bill along to the Senate.
"That is a legislative strategy. No secret there. But you know this is important that we get it right. And I want to make sure that we're taking the time to get it right," she said.
The Senate has a much tighter majority — only 51 Republicans to 49 Democrats — than the House. Because the bill has been passed using Budget Reconciliation, the Senate only needs 51 votes to pass it, but its contents must remain limited to matters of budget and revenue.
But overall, the Senate is far more moderate in its approach, and more Republicans — including Murkowski — are opposed to removing requirements to offer same-cost insurance to people with pre-existing conditions, or peeling back Medicaid expansion.
Negotiating for future wins
Thursday's vote was not only about advancing the House bill, Young said.
By backing his party's efforts, he gained more clout to pass future legislation that can benefit Alaska, he said.
"This is what you have to remember — it's like a baseball game that goes into overtime. You go to bat a lot of times and you want to make sure you finally get a hit. I believe very strongly that I'm in a position now that throw me a softball and I'm gonna get a hit," Young said.
"You have to have the assurance and the backing of leadership, or your bills don't move," he said. "Alaska has a lot of things on the plate, and I think we're in a better position to get legislation done for Alaska after the vote today than I was before."