While there have been several reports about the prospects of the American Health Care Act (“AHCA,” “Trumpcare” or “Ryancare,” depending on who you ask), please be mindful that in 2009-10, many people thought the Affordable Care Act (i.e., “Obamacare”) was dead several times before the bill ultimately passed. Critics of AHCA should exercise restraint; it’s far too early to write the bill’s obituary.

House of Representatives

Speaker Paul Ryan (R-WI) has been shepherding the AHCA methodically through the House Committee process. Both the House Ways & Means Committee and the House Energy & Commerce Committee debated and voted on AHCA last week, notably before the Congressional Budget Office (“CBO”) released its assessment (i.e., score) of the legislation last Monday, March 13.

The House Budget Committee advanced the AHCA to the Rules Committee on Thursday, March 16, its last stop before consideration by the larger House of Representatives.

The House will vote this Thursday, March 23 on the legislation, an indication that Speaker Ryan may be feeling confident that he has secured the 216 votes the AHCA needs to pass. In order to lockdown those votes, the Speaker agreed to a package of amendments that include the following:

  • Option for states to receive Medicaid per capita caps or block grants.
  • Option for Medicaid work requirements for able-bodied people.
  • A more generous Medicaid inflation adjustment for the elderly and disabled.
  • Repeal of the ACA’s taxes will occur in 2017 instead of 2018; repeal of Obamacare’s Cadillac tax will occur in 2025 as opposed to 2026.
  • A prohibition on additional states expanding Medicaid.

All of this movement shouldn’t be confused for consensus among GOP members. There are still deep divisions, as evidenced by the reaction of many conservative House Republicans last night who explained that these amendments still haven’t addressed their most pressing concerns with the legislation. Reports that the bill will have to undergo additional changes in order to pass the Senate appear accurate. But as Speaker Ryan noted late last week, this is how the legislative process is supposed to work.

Senate

The Senate debate over AHCA won’t begin in earnest for a couple of weeks, but in many respects the battle lines have already been drawn.

Senator Rand Paul (R-KY) has already said he won’t vote for the AHCA, and Senators Ted Cruz (R-TX), Tom Cotton (R-AK), and Mike Lee (R-UT) have been critical of the bill as well. They all explain that they oppose the bill because it isn’t conservative enough, arguing that the government’s role in the health-insurance market should be dramatically curtailed.

Senator Susan Collins (R-ME), among others, has also announced her opposition to the legislation as currently written, although her opposition is rooted in the belief that the legislation will ultimately result in too many people losing coverage. She is but one person in a group of more moderate Republicans being called the “Coverage Caucus.”

President Trump is doing his part to secure the necessary House votes to pass the AHCA. This morning the President heads to Capitol Hill to meet with Republican House Members. President Trump met last Friday morning with several GOP House Members, including members of the influential Republican Study Committee. After the meeting, President Trump said “every single person in this room is now a ‘yes’” on AHCA.

Worth noting is the strong pushback by the Administration on the CBO score released last week. In its criticism, the White House noted that the AHCA was never intended to encapsulate the entirety of the repeal and replace effort; defenders of the effort note that the AHCA is only one part of a three-phase process that includes significant regulatory reforms by Secretary Price and the Administration.

To that end, Secretary Price gave House Republicans a preview of the next regulatory steps HHS is planning to ease Obamacare’s rules. Next steps reportedly include efforts to stabilize the individual health insurance market and a measure to soften the ACA’s “essential health benefit” requirements.

Four key GOP governors – John Kasich (R-OH), Rick Snyder (R-MI), Brian Sandoval (R-NV), and Asa Hutchinson (R-AK) – have expressed serious concerns with the AHCA, arguing that if enacted in its current form, the legislation would not give states enough flexibility or adequate money. This opposition is significant. Republicans are already divided on how to end the ACA’s Medicaid expansion, and disapproval from these influential governors is likely to resonate with some Republicans. It’s worth noting that all four states expanded Medicaid (Michigan and Arkansas did so in a revised form).