On Friday afternoon President Donald Trump and Speaker Paul Ryan (R-WS) pulled the American Health Care Act from a floor to prevent a vote that would have ended in defeat.  The loss came after a tumultuous week of changes to the bill just a few days earlier.

Essentially Ryan could not come up with a bill that would satisfy the most conservative members of his party who are fundamentally opposed to a guarantee of heath care and more moderate members who were concerned about the impact on their districts if some of the 21 million people that had health care because of the ACA lost that coverage.

The bill became more conservative as the week wore on.  The modified bill would have allowed states to take an outright block grant of Medicaid, some other cuts and work requirements.  In addition, the essential benefits package was cut back.  The essential benefits package requires all plans to cover ten essential benefits including mental health and drug treatment coverage, maternity coverage, emergency room care and several other vital services.

Conservatives were particularly adamant about wanting to eliminate substance abuse coverage, requirements that insurance companies cover people with pre-existing conditions and requirements that allow parents to cover their adult children to age 26 among several items.  Ultimately the Freedom Caucus wanted a straight-out repeal of the ACA with no replacement.  As the Speaker cut away at benefits he attempted to pacify more moderate members.  The modified bill would have provided $15 billion in funding that was intended to help address a loss of mental health services. The modifications also provided $85 billion in added tax relief for older adults but that would have been added later in the Senate.

The back and forth did not cover any additional people. After the original analysis, the Congressional Budget Office (CBO) updated its original required analysis on Thursday, March 23.  The new analysis indicated that the legislation’s deficit reduction over ten years would go down from $337 billion to $150 billion.  The updated analysis continued to show that 14 million people would become uninsured next year (2018), 21 million would lose insurance by 2020 and in ten years, (2026) 24 million more people would be without health insurance compared to current ACA law.

The bill had been scheduled for a debate and vote on Thursday.  It was delayed when the votes were not there.  Then late Thursday President Trump played hardball by demanding a vote instead of allowing for on-going negotiation.  The hardball tactic did not work.

The President met with some conservatives over the short period but in one of the last meetings he rejected discussion on specific changes to the bill that conservatives were seeking and instead made a plea on the basis of party and presidential, loyalty.  The gambit failed and when some surprising members came out again the bill on Friday morning, especially new Appropriations Committee Chairman Rodney Frelinghuysen (R-NJ).  Then support seemed to be going in the opposite direction.

Next Steps For ACA

The President has denounced the ACA and argues it will fail.  Something the Administration could assist in with HHS undercutting future outreach, enforcement of the law and cutting certain funding.  None-the-less 21 million have insurance because of the law.  That will certainly remain the case for the 11 million getting their coverage through Medicaid, something that will continue.  It is also possible that some of the19 states that have passed on Medicaid expansion could reconsider depending on Congressional behavior.  The reconciliation tool is still available for both the House and Senate as written, if they hold off on writing up the next reconciliation.  They are likely to have some time to decide since Congress is expected to break for two weeks starting around April 6 to 8.  The Senate could also take its own action if they are so motivated.

Next Political Steps

The President and Speaker have both discussed a pivot to tax reform.  Some have suggested that the disagreements there could be just as great within the Republican party.  It is also not clear whether they would seek a totally partisan write-up.  On occasion Senate Finance Chair, Senator Orrin Hatch (R-UT) has suggested a more bipartisan effort but they may be a challenge especially if the House package includes boarder taxes or cuts that are tilted to higher income taxpayers.

A bigger reality is that Congress still has to deal with the rest of FY 2017 funding.  That expires on April 28, and after the Congress returns from the break.  It will be front and center before any tax debate.  The President has asked for an increase in Defense Department and Homeland Security funding of $33 billion with $18 billion being cut from the current year domestic funds.  In addition, that request includes initial funding for the US-Mexican border wall.  That is something Democrats have suggested they would block even if it comes to a government shutdown.