On May 4, the U.S. House passed the American Health Care Act (AHCA) seven years after Republicans pledged to repeal the Affordable Care Act (ACA). Twenty Republicans voted no on the legislation. At this time, the Congressional Budget Office has not issued a score for the House-passed version of the AHCA.

The legislation underwent a number of amendments over the Easter recess and the days leading up to the May 4 vote, including changes negotiated by Vice President Mike Pence; House Freedom Caucus Chairman Mark Meadows, R-N.C.; and House Tuesday Group member Tom MacArthur, R-N.J. The so-called “MacArthur Amendment” would allow states to seek waivers from the ACA’s essential health benefit requirement, the age rating requirement and the ACA’s community rating rules for individuals who fail to maintain continuous coverage. For states that pursue, secure and implement waivers, the result could be noncoverage of benefits included in the essential health benefits package — such as prescription drugs, maternal and newborn care, treatment for mental health conditions, and habilitative and rehabilitative care. It also could lead to increased costs and reduced protections for older Americans and individuals with pre-existing conditions who do not maintain continuous coverage.

The legislation now heads to the Senate, where lawmakers are expected to redraft significant portions of the bill to meet the chamber’s procedural rules. Some Senators have suggested a preference to write a new bill rather than working to amend the AHCA. GOP leaders can lose no more than two votes in the Senate if they hope to pass legislation under the budget reconciliation process, which requires only 51 votes to pass the Senate, but can be used only for legislation that directly affects the federal budget.