Intended for healthcare professionals

Observations Yankee Doodling

Will the Republican replacement for Obamacare become law?

BMJ 2017; 356 doi: (Published 13 March 2017) Cite this as: BMJ 2017;356:j1291
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, professor of family medicine at Georgetown University, and associate editor, The BMJ
  1. dkamerow{at}

Coverage: down; cost: as yet unspecified; future: uncertain

With great fanfare the Republicans have introduced and fast tracked their long awaited answer to the Affordable Care Act (“Obamacare”). As has been well reported, the American Health Care Act would remove key provisions of the current law, such as the individual mandate (the requirement that everyone purchase health insurance), the subsidies that help poor and lower middle class people do that, and the taxes on the wealthy that support those subsidies, and from 2020 it would roll back the massive expansion of Medicaid that has covered poor people in states that accepted it.12 While making these changes, the bill maintains some Obamacare provisions that proved popular, such as the required coverage of pre-existing conditions, banned lifetime caps on insurance payments, and coverage of dependants on their parents’ insurance until age 26.

Two versions of the 66 page bill have already passed the first of several congressional hurdles, emerging unchanged from the substantive committees in the House of Representatives where they were introduced. Ahead lies the budget committee, where the two bills will be combined, followed by a quick trip to the rules committee, before a vote on the House floor, which is scheduled to occur by the end of the month. At some point in this process the Congressional Budget Office is expected to weigh in with its impartial estimates of what the bill would cost, in dollars, health insurance coverage—and lives.

All this is taking place despite a huge outcry from critics on both left and right. Conservatives, who think the bill does not go far enough in dismantling Obamacare, have been meeting with everyone from the president down to express their concerns. They may be appeased by last minute amendments that will likely occur on the House floor, such as bringing the date for the Medicaid reversals forward by two years to 2018 and mandating that able bodied Medicaid recipients be working to receive benefits. If this happens, it seems likely that the (modified) bill would pass the House.

Critics on the left and from mainstream medicine have also been vocal about the changes in insurance coverage. In addition, public health advocates are furious that almost $1bn of annual funding to the Centers for Disease Control and Prevention for prevention, vaccination, and other public health programs has been eliminated.3 Women’s health supporters are similarly unhappy about the defunding of Planned Parenthood’s contraceptive and cancer screening activities. The outpouring of opposition to the bill, however, has had virtually no effect on the House.

Senate vote crucial

The big question has always been whether the bill could pass the Senate, with its razor thin Republican majority. Assuming that the Democrats hold firm in opposition, it would take only three Republican senators voting against the bill to defeat it.

Conservative and libertarian senators, such as Rand Paul from Kentucky, have been biting in their criticisms of the bill as introduced but may be mollified by subsequent amendments. If so, that will leave the fate of the bill, and of the dramatic changes it would bring, up to two small groups of Republican senators. The first, led by two female senators, is appalled by the defunding of Planned Parenthood and its activities. The second, led by Republican senators from large states with huge Medicaid populations, is concerned about the effect of the bill on their states’ budgets and Medicaid recipients, especially those in opioid addiction treatment. Both groups will be under extraordinary pressure to join their party leadership and support whatever bill finally reaches the Senate floor. If it comes to this, it will make for high stakes political theater, with the potential to make instant statesmen (and stateswomen) of those who vote on their convictions rather than follow their party line.

Stay tuned.



View Abstract