Intended for healthcare professionals


US Representatives vote to repeal Affordable Care Act

BMJ 2017; 357 doi: (Published 08 May 2017) Cite this as: BMJ 2017;357:j2217
  1. Michael McCarthy
  1. Seattle

By a narrow 217 to 213 margin, the US House of Representatives passed legislation on 4 May that, should it become law, will repeal major provisions of the 2010 Affordable Care Act. No Democrats voted for the legislation, and 20 Republicans voted against it.

The bill, called the American Health Care Act, now goes to the Senate where most observers believe it stands little chance of passage in its current form. Republicans have only a three vote majority, and several key Republican moderates have already said that the bill will cause too many of their constituents to lose coverage. Of particular concern are provisions that cut funding for Medicaid and phase out its expansion—a provision of the Affordable Care Act that is credited with increasing the number of people with insurance by more than 14 million.

However, at a celebratory gathering at the White House, President Donald Trump said that he was confident that the bill would be passed by the Senate. “This is a repeal and replace of Obamacare. Make no mistake about it,” Trump said.

An analysis by the non-partisan Congressional Budget Office of an earlier version of the bill estimated that its passage would have resulted in 32 million fewer people having insurance by 2026.1 Republicans chose to vote on this bill before the CBO could analyze the impact of the legislation.

Under the Republican bill, there will no longer be a mandate requiring everyone to have health coverage or pay a penalty. This was perhaps the most unpopular provision of the Affordable Care Act. Supporters of the mandate have argued that it was necessary to keep premiums down by expanding the risk pool with younger, healthier, lower cost enrollees.

The Republican legislation instead requires people who go without insurance for more than two months to be subject to a 30% increase in the price of their premiums should they then seek to buy insurance. This surcharge, supporters of the bill said, will discourage people from waiting until they are ill before buying coverage.

The legislation will also let insurers charge older enrollees more. Under the Affordable Care Act, insurers could only charge older enrollees three times what they charged their youngest. Under the Republican bill, insurers would be allowed to charge up to five times as much, and more in states that obtain a waiver from the federal government. Supporters of the provision said that this will reduce premiums for younger individuals, encouraging their enrollment. But opponents predict the provision will add thousands of dollars to premiums for older people, making coverage unaffordable for many.

The bill retains the Affordable Care Act’s provision that requires insurers to sell health plans to people with pre-existing conditions, the act’s most popular provision. However, an amendment to the bill would let states apply for waivers that would make it possible for insurers to raise premiums for those with pre-existing conditions who sign up after going without insurance.

Opponents of the bill say such waivers will lead to price rises that will stop people with pre-existing conditions from getting insurance. To tackle this, the bill creates an $8bn (£6.2bn; €7.3bn) fund to create a pool for those with pre-existing conditions unable to obtain insurance—a sum, critics say, that will prove to be far too little.

The bill also lets states obtain waivers so that insurers can sell plans that do not cover the essential health benefits that must to be included in plans under the Affordable Care Act. These benefits include coverage for maternity care, prescription drugs, mental health treatment, and preventive services. Supporters of the bill say this will let people buy lower cost plans that better meet their needs. But opponents say insurers will sell bare bones plans that provide little protection and, by making such services as maternity care optional, the plans will discriminate against women.

The legislation has been opposed by many leading physician, patient, and health industry groups, including the American Medical Association, the American College of Physicians, and the American Hospital Association. In a statement, Andrew Gurman, president of the American Medical Association, said: “America should not go backward to the time when our fellow citizens with pre-existing health conditions faced high costs for limited coverage, if they were able to obtain coverage at all. We urge congressional leaders and the administration to pursue a bipartisan dialogue on alternative policies that provide patients with access to high quality care and preserve the safety net for vulnerable populations.”