What Now for the Affordable Care Act?

The Republican seven-year effort to repeal the Affordable Care Act (ACA) finally seemed likely to become successful this year with the election of a Republican President in 2016 and retention of Republican control of both houses of Congress. Although earlier efforts had been focused simply on repeal of the ACA, the new Administration and Congress put a focus on repeal and replace with something better.

As reflected in the below timeline, the ACA repeal and replace effort became the first significant focus for major legislation in 2017.

The Senate in January voted to allow ACA repeal through the budget reconciliation process, helping to avoid the 60-vote requirement under the filibuster rules of the Senate – important since the Republicans hold only a slim 52 to 48 edge in the Senate.  Also, as soon as inaugurated, President Trump signed an executive order directing relevant departments to take action to ease burdens imposed by the ACA until repeal and replace legislation was enacted.

However, internal disagreements among Republicans as to what the replacement bill should look like soon led to problems.

The House vehicle, the American Health Care Act, was announced in March but then pulled for lack of votes.  Modifications were finally made to achieve passage by a narrow 217 to 213 majority in May.  The Senate then took up the legislation and the problems between factions of the Republican Party continued.  Even the vote to agree to debate repeal and replace legislation required the vote of the Vice President to pass on a 51 to 50 vote.  The Senate version of the bill, the Better Care Reconciliation Act (BCRA), then failed to pass on a 43 to 57 procedural vote in July.

The Senate next tried to go back to a repeal only bill that had passed the Senate in 2015, and it failed on a 45 to 57 vote.  The final Senate effort to preserve the legislation was to vote on a “skinny repeal” bill that only eliminated the health insurance mandates of the ACA and a couple of other provisions.  This legislation was viewed as legislation not to be enacted but just as a vehicle to get to a House/Senate conference committee where a compromise bill could hopefully be drafted.  However, even the skinny repeal bill failed on a dramatic 49 to 51 vote.

While Congressional focus is now shifting to tax reform, Republican leaders have promised a return to health care reform when the time seems right.  A bipartisan effort is underway in the Senate to draft provisions to shore up the ACA and make it more viable at least for 2017.  President Trump has threatened to cut off funds to health insurers viewed as vital to the continuation of the ACA to force Congress to try again on another repeal and replace effort, but he has not taken action to withhold funds so far.


If no action is taken and funding continues, the ACA could continue to struggle on, although decreased participation by health insurers in the ACA exchanges would be likely to continue and premiums would likely continue to increase as the ACA continues to fail to attract sufficient numbers of younger, healthier people to participate in the exchanges. It is unclear at this point which of these or other possible futures await the ACA.  In the meantime, the ACA taxes remain in force, although there is some doubt as to how vigorously the IRS will enforce the individual and employer mandates.


Mark Luscombe

All stories by: Mark Luscombe