Republicans in the House of Representatives say they will vote on a plan to repeal and replace the Affordable Care Act on Thursday, putting a bill largely negotiated in secret and revised at the last minute to the test in one of the tensest congressional standoffs in recent memory.
GOP leadership is pushing the vote under pressure from President Donald Trump's White House and conservatives in the House, despite opposition from virtually every major medical organization and a Congressional Budget Office review of a prior version showing it could kick more than 24 million people off of insurance.
The new version of the bill, released less than a day before the planned vote, seems to have persisted largely unchanged in structure.
But it does have additional concessions to appease the House's arch-conservative Freedom Caucus, which won language that would allow insurers to charge people with pre-existing conditions much more for health care. In exchange for the waivers, the amendment proposed by Michigan's Rep. Fred Upton will provide $8 billion in funds to assist the people with pre-existing conditions who would pay more under those waivers — a relative pittance in health care funding terms.
Republicans' first attempt at the American Health Care Act — a bill that ended the ACA's employer and individual mandates and replaced its system of subsidies with significantly less generous tax credits and cut taxes dramatically on the wealthy — failed disastrously after GOP legislators rejected the consensus position and never proceeded to vote.
Health groups and medical organizations have denounced the Republican plan. The CBO concluded the prior version would result in at least 24 million fewer people having health insurance by 2026, while a Vox analaysis concluded it would spike many ACA enrollees' premiums by thousands of dollars.
It's unclear whether the new bill will pass muster, even in the conservative House. While the Freedom Caucus thought the original bill was insufficiently radical, it was similarly opposed by moderates, who feared the bill's cuts to Medicaid would spell disaster for low-income constituents.
Yet even more unclear is what the exact impact of the revised version might be. Since Republicans broke their own promise to post legislation online three days before voting on it, no one, including the CBO, has had time to run new numbers on it.
In other words, it's being railroaded through without any foreknowledge of what the impact might be, despite health care spending comprising nearly a fifth of the United States' entire economy.
What is clear is that the revised version is substantively similar to the prior effort, meaning all of its potential consequences are likely to ensue.
Even if it passes the House, Republicans will face a rockier road in the Senate, where their path to a narrow majority vote is razor thin and losing just a handful of GOP senators could tank the bill. The original version of the bill could only be passed there via reconciliation, a process by which the Senate can approve legislation by a straight majority vote of more than 50 senators if it only affects spending.
The provisions added to please the Freedom Caucus in the House are not fiscal, meaning the GOP majority may not be able to invoke reconciliation rules — meaning they would need 60 votes to pass the bill without a Democratic filibuster, support which simply does not exist.