House Republicans narrowly approved a controversial plan to dismantle the Affordable Care Act on Thursday, taking a significant first step toward fulfilling a seven-year promise to repeal and replace the 2010 law that served as a landmark overhaul of the US healthcare system.
Republicans passed the American Health Care Act with one vote to spare, following a dramatic series of negotiations that exposed deep fissures between the party’s moderate and conservative wings over how to replace Barack Obama’s signature legislative accomplishment.
The bill passed 217 to 213, with 20 Republicans voting against and no Democrats voting in favor. Republicans burst into applause when the bill passed the 216-vote threshold, a feat that had seemed insurmountable just days before.
Democrats too saw a reason for celebrating. After it passed, they sang the 60s hit Na Na Hey Hey (Kiss Him Goodbye) – appearing to suggest Republicans would lose their seats if the repeal proved unpopular.
The bill now moves to the Senate, where it is expected to face serious difficulties.
Later in the afternoon, an exultant Trump celebrated with dozens of Republican congressmen at the White House. He punched the air in triumph as he greeted them in the Rose Garden and was met with sustained applause. Before a seated audience that included Ivanka Trump and Jared Kushner, vice-president Mike Pence declared: “Thanks to the leadership of President Donald Trump, welcome to the beginning of the end of Obamacare.”
“What a great group of people,” Trump said, referring to the Republican congressmen, “and they’re not even doing it for the party, they’re doing it for this country because we suffered with Obamacare.”
He described Obamacare as a “catastrophe” and “essentially dead”, adding: “If we don’t pay lots of ransom money over to insurance companies, it would die immediately.”
Despite reservations expressed by senators, the president predicted the new bill would survive the upper chamber. “We’re gonna get this passed through the Senate,” he said, adding, “I actually think it will get even better. And make no mistake, this is a repeal and a replace of Obamacare. Make no mistake about it.”
He added: “As much as we’ve come up with a really incredible healthcare plan, this has brought the Republican party together.” Next, he promised, would be the biggest tax cut in US history.
House speaker Paul Ryan was smiling as he faced the media. “It really was a collaborative, consensus-driven effort,” he said.
Member after member took care to lavish praise on Trump. Majority leader Kevin McCarthy told the gathering: “I’ve only been through a few presidents but I’ve never seen someone so hands on. I walk into my office yesterday morning and they say the president’s calling again … The president gives me a list of who he thinks I would be best to talk to on the list. And he was right.”
It was a very different spectacle from the first attempt to pass the healthcare bill in March, which ended with a crestfallen Ryan admitting to reporters on Capitol Hill that moving from opposition to governing comes with “growing pains”.
But faced with mounting pressure from Trump and a White House eagerly searching for a victory of its own, Republicans managed to coalesce around a flagging plan that just six weeks ago was considered all but dead.
As the president approached his 100th day in office without a single legislative victory to his name, the White House escalated its push on Republicans to revive the effort to repeal Obamacare, a significant campaign promise. Behind the scenes, New Jersey congressman Tom MacArthur, a moderate, teamed up with North Carolina congressman Mark Meadows, chairman of the arch-conservative Freedom Caucus, to hammer out a compromise.
“It’s real easy to be unified when your vote doesn’t matter and you’re in the minority,” Meadows said before the vote on Thursday. “It’s much more difficult to be unified when you’re in the majority, and that’s what we’re seeing.”
Ahead of the vote, members took turns delivering impassioned speeches from the chamber floor, drawing rare applause and cheers.
“A lot of us have been waiting seven years to cast this vote,” said Ryan, imploring his party to make good on their promise to repeal the ACA.
As Ryan finished, Republicans rose to their feet, chanting “Vote! Vote! Vote!” Democrats countered: “Where’s the score?” a reference to Ryan’s decision to vote on the bill before the independent Congressional Budget Office (CBO) could provide an analysis on how it would impact voters.
“Most Americans don’t know who their member of Congress is,” Democratic House minority leader Nancy Pelosi said. “But they will now when they find out that you voted to take away their healthcare.”
“You,” Pelosi said, singling out moderate Republicans, “have every provision of this bill tattooed on your forehead. You will glow in the dark on this one.”
“To have a healthcare bill that throws 24 million people off insurance – you should be ashamed,” Democrat Jim McGovern, a Massachusetts congressman, said in rebuke to Republicans.
The revised healthcare bill was immediately mired in controversy, as Democrats vowed to wage the upcoming 2018 midterms over the legacy of Obamacare and its expansion of coverage to millions of Americans.
The Republican plan has drawn particular scrutiny for gutting coverage for people with preexisting medical conditions. Prior to the passage of Obama’s healthcare law, insurers were able to deny coverage to people who were already sick and whose treatment was more expensive.
The Republican bill would allow states to opt out of coverage for preexisting conditions, a move conservatives argue would lower overall premiums by removing sick people from the market. An estimated 27% of Americans under 65 have preexisting conditions, include cancer, heart disease and diabetes, that were not covered prior to the ACA.
To attract support from moderate Republicans who balked at the plan, an additional $8bn was included over five years to fund so-called high-risk pools for people with preexisting conditions – but states that opted out would not be required to.
Health policy experts have argued the fix is insufficient. At least one analysis, from the left-leaning Center for American Progress, found the Republican plan would fall woefully short in providing coverage to individuals with preexisting conditions.
The Republican healthcare plan also includes an attempt to defund women’s health organization Planned Parenthood, as well as drastic cuts to Medicaid, totaling $370bn over a decade. A broader portrait of the bill’s potential consequences was unclear, because Republicans rushed a vote before the CBO could provide an analysis. The office had projected that as many as 24 million Americans would lose their health insurance under the original version of the Republican plan.
While Republican lawmakers acknowledged they would prefer to first see a CBO score, most resigned themselves to instead favor the passage of a bill they could tout as progress toward repealing and replacing the ACA.
It was an almost stunning about-face for a party that for years railed against Democrats for what they said was a rushed, backroom process to pass the ACA in 2010. (The debate over the legislation was actually far more protracted than characterized.) The latest version of the Republican bill, the text of which was still evolving overnight, was not posted until late Wednesday night – less than 24 hours before the vote.
Meadows, who long blasted the Democrats as rushing Obamacare through, pushed back on accusations that Republicans were being hypocritical.
“I have read the bill no less than six times,” he said. “If they haven’t read the bill it’s because they haven’t the spent the time to do that.”
In the Senate’s hands
Whether Republicans’ seven-year mission to dismantle the ACA comes to fruition now lands squarely in the hands of the Senate.
Faced with a far more narrow majority in the upper chamber, Republicans plan to use a process known as budget reconciliation that would allow them to avoid a Democratic-led filibuster and pass a bill with a simple 51-majority vote. But the rules of that process pose their own hurdles, as they limit the scope of what can be passed through reconciliation to spending, taxes or the deficit. The House-passed bill would thus need to undergo substantial changes.
Republicans in the Senate signaled they were in no hurry to advance a healthcare bill.
“My guess is we’re going to spend at least a month looking at the issue,” Republican senator Bob Corker of Tennessee told MSNBC.
House Republicans said they expected the Senate to make changes to the legislation, with the goal of ultimately improving it. But that would tee up another vote in the House on its final passage and potentially reopen the chasm between the GOP’s moderates and its right flank.
Democratic Joe Manchin, a senator from West Virginia facing a tough re-election battle next year, made clear Republicans were on their own as they eyed next steps.
“I can’t say [the Republican bill] is dead on arrival,” he told Politico in an interview.
“But they don’t have 60 votes, so it’s dead on arrival.”