“Real change begins with immediately repealing and replacing the disaster known as Obamacare."
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“Real change begins with immediately repealing and replacing the disaster known as Obamacare."
The promise to repeal and replace the Affordable Care Act, the sweeping health insurance law also known as Obamacare, regularly drew roars of approval at Trump campaign rallies. There was a two-year window when Republicans held both the House and the Senate that President Donald Trump might have had enough votes to deliver.
The effort fell short in 2017 when three Senate GOP defectors stalled the Republicans' best hope for repeal.
The party did successfully neutralize the penalty on people who were able to afford health insurance but chose not to buy it. The requirement to buy health insurance, known as the individual mandate, was one of the least popular provisions in the Affordable Care Act. In their 2017 tax bill, Republicans set the penalty at zero.
By itself, the move did not wipe out Obamacare. But it did have a big impact. It opened the door to a multi-state lawsuit that led a federal judge in Texas to declare the entire law unconstitutional.
The U.S. Supreme Court agreed to hear the appeal, but not before October, with a ruling likely to come in 2021. (The court upheld the individual mandate in 2012.)
"There is no chance the Senate will pass anything plausible on Obamacare repeal and replace this year," said University of Pennsylvania law professor Allison K. Hoffman.
Hoffman said there is no consensus health care plan in the Senate. More than that, as the coronavirus has led to layoffs that stripped workers of their employer-sponsored health insurance, top Republicans have encouraged those people to sign up for plans available on the marketplaces set up by Obamacare.
Even if the Senate passed a bill, the Democratic House would kill it. We rate this Promise Broken.
The Hill, Cornyn: Those who have lost employer health care can sign up for ObamaCare, May 13, 2020
Austin PBS, A Conversation With U.S. Senator John Cornyn, May 12, 2020
Email exchange, Allison K. Hoffman, professor of law, Penn Law School, June 22, 2020
Repealing and replacing Obamacare was one of President Donald Trump's key promises in the 2016 campaign. Full repeal eluded him in 2017, but Republicans were able to effectively neutralize the penalty on people who might be able to afford health insurance but choose not to buy it.
The individual mandate, as it is known, was one of the least popular provisions in the Affordable Care Act. In their 2017 tax bill, Republicans set the penalty at zero. By itself, as we noted in our last update, the move disrupted but did not wipe out Obamacare.
The tax change did have a big impact, though. It opened the door to a multi-state lawsuit that led a federal judge in Texas to declare the entire law unconstitutional.
U.S. District Court Judge Reed O'Connor ruled Dec. 14, 2018, that the "individual mandate 'is essential to' and inseverable from 'the other provisions of' the Affordable Care Act."
With the penalty set at zero, O'Connor said the mandate could no longer be justified as Congress using its taxing power to shape policy. So he threw out the mandate and with it, the rest of the law. He said the mandate was fundamental to making the law work.
But Obamacare lives on. O'Connor followed up with an order that put his first action on hold pending appeal.
That's where things stand, legally.
Politically, Democrats now control the House and their leader, Nancy Pelosi, D-Calif., plans to intervene in the appeals process to "reject Republicans' effort to destroy the Affordable Care Act."
For now, Democrats have said they will work to protect and preserve the Affordable Care Act. Thanks to the courts, however, uncertainty remains about the law's fate. We rate the promise to repeal Obamacare Stalled.
Texas, et al vs. United States of America, et al., Memorandum opinion and order, Dec. 14, 2018
Texas, et al vs. United States of America, et al., Order granting stay and partial final judgment, Dec. 30, 2018
The Republicans' successful drive to pass a massive tax bill allowed President Donald Trump to take another slice off of the Affordable Care Act. Effective 2019, the sweeping tax package repeals the penalty on people who might be able to afford health insurance but choose not to buy it. The individual mandate affects a relatively narrow sliver of Americans, but it has been a pillar of Obamacare.
The mandate was the stick to herd more people -- healthy people -- into the insurance pool. That would spread the risk, keep premiums down and produce a stable insurance market.
Fundamentally, it was the evil twin of a very popular feature of the health care law -- guaranteed coverage of people with pre-existing conditions. The deal was that if the government is going to force insurance companies to cover everyone, then it must deliver a big insurance pool with a lot of people who won't rack up medical bills. The mandate plays a similar role with the Affordable Care Act's community rating rules, which prevent the insurance companies from charging sick people more than healthy people.
Last year, about 6.5 million households paid the penalty (although many who did probably could have avoided it). In a Nov. 13 tweet, Trump called the mandate unfair and highly unpopular and urged the Senate to add repeal to its tax package. Trump got what he wanted.
Eliminating it does no favors for Obamacare's goal to get more people covered at a price they can afford.
The American Academy of Actuaries, the ultimate mavens of risk for the insurance industry, told lawmakers that if they simply got rid of the mandate and did nothing else, fewer healthy people would buy policies. "Premiums would increase as a result, reducing affordability and eroding pre-existing condition protections," said the academy's Shari Westerfield.
The Congressional Budget Office, the nonpartisan number crunchers for Congress, estimated that premiums would rise 10 percent. After 10 years, 13 million fewer people would be insured.
But even the CBO stressed how mushy any prediction is, noting that the actual impacts "would probably be smaller than the numbers reported in this document."
Larry Levitt at the Kaiser Family Foundation, a neutral source of health care data, said his sense is that at the end of the day, setting the mandate penalty to zero, which is what the tax law does, "will hobble the ACA, but not kill it."
"The heart of the ACA – the premium subsidies, the Medicaid expansion, and protections for pre-existing conditions – remain in place," he said. "The premium subsidies should provide enough of an incentive for many healthy people to get coverage to keep the individual market reasonably stable."
We reached out to other health care policy experts. Christine Eibner at the RAND Corporation emphasized that the effect of repeal is "highly uncertain."
Still, she told us that "on balance, I think the evidence suggests that the mandate is having some impact on enrollment, but it may be small relative to other factors such as the tax credits and subsidies."
"We don't really know," said Martin Gaynor, economist at Carnegie Mellon University. "If the mandate is important, then eliminating it will create big problems in the exchange marketplaces, which would likely prove difficult to reverse."
With this change, Trump continues to undermine the Affordable Care Act rather than replace it. He hasn't repealed the law officially, and we'll have to monitor how much repealing the mandate affects the Affordable Health Care Act's overall goals. Our rating for this promise remains as before, In the Works.
IRS, Letter from IRS Commissioner John Koskinen to Congress, Jan. 9, 2017
Kaiser Family Foundation, How Many of the Uninsured Can Purchase a Marketplace Plan for Less Than Their Shared Responsibility Penalty?, Nov. 9, 2017
Brookings, Repealing the individual mandate would do substantial harm, Nov. 21, 2017
American Academy of Actuaries, Potential Adverse Consequences of Eliminating the Affordable Care Act's Individual Mandate, Dec. 12, 2017
New England Journal of Medicine, The Importance of the Individual Mandate — Evidence from Massachusetts, Jan. 27, 2011
U.S. House of Representatives, Text: Tax Cuts and Jobs Act, Dec. 14, 2017
Journal of Health Economics, Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act, March 6, 2017
Congressional Budget Office, Repealing the Individual Health Insurance Mandate: An Updated Estimate, November 2017
Axios, The ACA stability "crisis" in perspective, Aug. 10, 2017
Email interview, Martin Gaynor, professor of economics and health policy, Carnegie Mellon University, Dec. 19, 2017
Email interview, Larry Levitt, senior vice president, Kaiser Family Foundation, Dec. 19, 2017
Email interview, Christine Eibner, senior economist, RAND Corp.,Dec. 19, 2017
After failing in several attempts to pass legislation overturning the Affordable Care Act, the Trump administration took a big step toward undercutting the law Oct. 12 when it said it would no longer continue funding a class of widely used subsidies without congressional appropriations.
The payments in question are known as "cost-sharing reductions." They were intended to ease copayments and deductible costs for millions of low-income Americans who have purchased insurance coverage on the Affordable Care Act online marketplaces. The estimated cost of the payments was $9 billion next year and nearly $100 billion over the next decade.
The payments have been subject to a legal dispute since House Republicans sued in 2014, arguing that the Obama administration was improperly paying the subsidies when no money had been appropriated for that purpose by Congress. The House Republicans' lawsuit was initially upheld in federal district court, but the case has continued to work its way through the courts.
In its announcement, the White House specifically cited the legal case as the reason for ending the payments. Insurers had been expecting a new round of payments on Oct. 18.
"Based on guidance from the Department of Justice, the Department of Health and Human Services has concluded that there is no appropriation for cost-sharing reduction payments to insurance companies under Obamacare," said a statement from the White House press secretary's office. "In light of this analysis, the Government cannot lawfully make the cost-sharing reduction payments. … Congress needs to repeal and replace the disastrous Obamacare law and provide real relief to the American people."
Health policy specialists agreed that the impact could be serious.
What the president is doing "is a haphazard chipping away" of the parts of the law he can reach, said Linda Blumberg, a senior fellow at the Urban Institute. "It's a very reckless way to make policy because its effects vary considerably across the country and in some cases will destabilize insurance markets with no strategy or policy for fixing them."
Experts said that lower-income Americans would be hurt the most by the change.
"The people in the exchanges are disproportionately low income, most below 225 percent of poverty level, and therefore get support from the cost-sharing reductions," said Gail Wilensky, who headed Medicare and Medicaid under President George H.W. Bush. Stopping those payments is "a big deal," she said.
But ending the subsidies could have other indirect impacts, experts said.
Some states anticipated the possibility that the Trump administration would stop paying cost-sharing reductions and had the insurers they regulate factor this into their proposed premiums for 2018. But other states did not.
In those states that didn't plan for this scenario, the non-group market -- that is, the market for insurance purchased individually by consumers rather than collectively by employers for their workers -- could face the most significant impacts.
"This would mean insurance costs for nongroup coverage becoming substantially higher," Blumberg said. "This scenario still leaves the nongroup market regulations in place, but it hurts everyone because those eligible for subsidies who can't afford coverage on their own would have to drop out and become uninsured. Since many of these people are healthy, the premiums for all that remain in the insurance system would go up."
Ending the subsidies will not necessarily be tantamount to repealing the law, as Trump promised to do.
For starters, the cost-sharing reductions are one part of the law; eliminating them would not directly affect other parts.
"Obamacare is many things -- Medicaid expansion, insurance regulations, consumer protections, the health insurance exchanges, Medicare benefit improvements, the individual and employer mandates, cost control and delivery system reforms, and much more," said Jonathan Oberlander, a professor in the Department of Health Policy & Management at the University of North Carolina-Chapel Hill. Trump's move "is a big deal, and could further destabilize the ACA's insurance marketplaces. But … it doesn't impact the other components of Obamacare."
Trump's decision to end cost-sharing reduction payments puts the Affordable Care Act in some degree of peril. We rate this promise In the Works.
White House, statement from the press secretary on cost-sharing reductions, Oct. 12, 2017
New York Times, "Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again," Oct. 12, 2017
Washington Post, "White House tells court it is immediately stopping ACA cost-sharing subsidies," Oct. 13, 2017
Email interview with Joseph R. Antos, health policy specialist at the conservative American Enterprise Institute, Oct. 13, 2017
Email interview with Jonathan Oberlander, professor in the Department of Health Policy & Management at the University of North Carolina-Chapel Hill, Oct. 13, 2017
Email interview with Gail Wilensky, head of Medicare and Medicaid under President George H.W. Bush, Oct. 13, 2017
Email interview with Linda Blumberg, senior fellow at the Urban Institute, Oct. 13, 2017
Attempts to repeal portions of the Affordable Care Act have failed in the past several months, leading President Donald Trump to issue an executive order expanding access to cheaper, less comprehensive health care plans.
The order, signed on Oct. 12, instructs federal agencies to remove certain limitations on "association health plans" and expand the availability of short-term health plans, both of which can skirt certain minimum coverage requirements included in the Affordable Care Act and state laws.
These changes will not immediately take effect; federal agencies will have to figure out how to act on Trump's directions.
The executive action orders agencies to explore ways in which the government can expand access to short-term health plans, which are available to individuals on a three-month basis and meant for people who are in-between health care coverage plans. Under the instructions, association health plans would be allowed to sell plans across state lines; those plans allow small businesses to band together to create cheaper health care plans that offer fewer benefits.
The order was intended to create more options for individuals seeking health insurance and help stimulate competition among insurers. Some health policy advocates worry that it could disrupt the insurance marketplace in a way that would drive up health care costs for elderly individuals and people with medical conditions.
Chris Hansen, the president of the American Cancer Society Cancer Action Network, criticized the action in a statement, saying the changes would create a rift in insurance coverage.
"If younger and healthier people leave the market, people with serious illnesses like cancer will be left facing higher and higher premiums with few, if any, insurance choices," Hansen said. "Moreover, those who purchase cheap plans are likely to discover their coverage is inadequate when an unexpected health crisis happens, leaving them financially devastated and costing the health care system more overall."
The National Association of Insurance Commissioners also raised concerns about the action, saying it could hurt "already fragile markets."
It will be months before changes are seen in the marketplace.
Trump has faced several hurdles in his plan to repeal Obamacare since taking office. Congress was unable to pass a repeal bill before a temporary rule allowing the Senate to move health care legislation through the chamber with only 50 votes ended on Sept. 30.
In an Oct. 10 tweet, Trump signaled he would use executive powers to move forward on his goal, saying: "Since Congress can't get its act together on HealthCare, I will be using the power of the pen to give great HealthCare to many people - FAST"
He dealt another blow to Obamacare regulations on Oct. 6, when his administration expanded employers' ability to exclude coverage for contraceptives in their health insurance plans.
"Today is only the beginning," Trump said during the most recent executive order signing. "In the coming months, we plan to take new measures to provide our people with even more relief and more freedom."
However, Trump can only accomplish so much with executive orders. He might be able to chip away at certain Obamacare provisions, but to fulfill his campaign promise, he will have to get Congress to pass legislation. We continue to rate this Stalled.
The White House, "Remarks by President Trump at Signing of Executive Order Promoting Healthcare Choice and Competition," Oct. 12, 2017
American Cancer Society, "Health Care Changes Could Leave Millions of Cancer Patients and Survivors Unable to Access Meaningful Coverage," Oct. 12, 2017
National Association of Insurance Commissioners, "Statement from Ted Nickel, NAIC President and Wisconsin Insurance Commissioner," Oct. 12, 2017
USA Today, "Trump's health insurance order pushes association plans to drive down costs — for some," Oct. 12, 2017
The New York Times, "Trump Administration Rolls Back Birth Control Mandate," Oct. 6, 2017
The Wall Street Journal, "Trump Executive Order Could Divide the Health Insurance Market," Oct. 8, 2017
The Washington Post, "Trump signs order to eliminate ACA insurance rules, undermine marketplaces," Oct. 12, 2017
President Donald Trump, tweet, Oct. 10, 2017
Another Senate attempt to repeal portions of the Affordable Care Act has ended, this time before going to a vote.
Senate Majority Leader Mitch McConnell announced a GOP-led health care bill would not go to a vote after three Republican senators said the bill did not have their support. In July, a similar partial-repeal effort died when Sens. John McCain, Susan Collins and Lisa Murkowski voted against it.
The latest bill, spearheaded primarily by Sens. Bill Cassidy, R-La. and Lindsey Graham, R-S.C., would have taken funding that is used under current law for Medicaid expansion and insurance subsidies and used it to fund block grants to states. A preliminary analysis by the Congressional Budget Office said the bill would have reduced the deficit by $133 billion by 2026 as well as resulted in millions more uninsured people compared to the current health care law.
McCain and Collins, along with Sen. Rand Paul, R-Ky., publicly voiced their opposition to the Graham-Cassidy bill.
Proponents of the bill only had a few weeks to gain enough support before a temporary process that allows health care legislation to pass in the Senate with 50 votes rather than the usual 60 ends on Sept. 30. Graham called it the GOP's "best and only chance" to meet its goal of repealing Obamacare.
However, that might not be true. After it became clear that the Graham-Cassidy bill was going to fail, President Donald Trump told reporters to expect new health care legislation to repeal portions of the Affordable Care Act in early 2018.
Until we see new movement on his promise to repeal Obamacare, we'll continue to rate this Stalled.
Congressional Budget Office, "Preliminary Analysis of Legislation That Would Replace Subsidies for Health Care With Block Grants," September 2017
CNN, "Senate won't vote on GOP health care bill," Sept. 26, 2017
New York Times, "Not Giving Up, Trump Insists He Has Votes to Repeal Obamacare," Sept. 27, 2017
YouTube, live stream of Graham-Cassidy bill press conference, Sept. 13, 2017
On the same day that Sen. Bernie Sanders introduced a single-payer health care bill, four senators on the Republican side of the aisle unveiled what they called their last attempt to roll back portions of the Affordable Care Act.
The bill, spearheaded by Sens. Bill Cassidy, R-La., Lindsey Graham, R-S.C., Dean Heller, R-Nev., and Ron Johnson, R-Wis., would replace federal funding currently being spent on Medicaid expansion, tax credits and subsidies with block grants, which state leaders could decide how to allocate. It would also end the medical device tax as well as Obamacare's individual and employer mandates.
Graham, in reference to Obamacare repeal efforts, told congressional Republicans during a Sept. 13 press conference, "This is your best and only chance to make it happen."
To pass the bill, the senators face a fleeting window of time. A temporary process that Republicans have been relying on to advance health care legislation in the Senate with 50 votes rather than the usual 60 votes will end on Sept. 30.
That process didn't quite work on July 28, when a bill to repeal portions of Obamacare died on the Senate floor after Republican Sens. John McCain, Susan Collins and Lisa Murkowski voted against it. (McCain was the final deciding vote.)
President Donald Trump applauded the new bill in a statement released after the press conference.
"I applaud the Senate for continuing to work toward a solution to relieve the disastrous Obamacare burden on the American people," Trump said. "My administration has consistently worked to enact legislation that repeals and replaces Obamacare, and that can pass the Senate and make it to my desk."
The bill is not a full repeal of Obamacare.
It is not yet clear if the bill has enough votes to pass the Senate, so for now we continue to rate this promise Stalled.
White House, "Statement by President Donald J. Trump on the Efforts of Senators Graham and Cassidy to Repeal and Replace Obamacare," Sept. 13, 2017
U.S. Sen. Graham Cassidy website, "Read About Graham-Cassidy-Heller-Johnson," Sept. 13, 2017
YouTube, live stream of Graham-Cassidy bill press conference, Sept. 13, 2017
USA Today, "Senate narrowly defeats 'skinny repeal' of Obamacare, as McCain votes 'no,'" July 28, 2017
Los Angeles Times, "Republicans face Sept. 30 deadline for fast-track Obamacare repeal," Sept. 1, 2017
Three Republican senators, along with the Democrats, put the brakes on President Donald Trump's promise to repeal Obamacare.
During the early morning hours of July 28, John McCain of Arizona, Susan Collins of Maine and Lisa Murkowski of Alaska voted along with the Democrats against repealing former President Barack Obama's signature legislation.
Senate Majority Leader Mitch McConnell of Kentucky said in a Senate floor speech after the vote that "it's time to move on," but Trump has shown no signs of backing down from one of his signature campaign promises.
After the Senate vote, Trump urged senators to continue the quest for repeal:
"Unless the Republican Senators are total quitters, Repeal & Replace is not dead! Demand another vote before voting on any other bill!" he tweeted July 29.
Trump senior advisor Kellyanne Conway said on Fox News Sunday the president would decide in the coming days whether to block subsidies in the health care law.
"He's going to make that decision this week, and that's a decision that only he can make," she said on July 30.
There are some other possibilities beyond full repeal of the law, including some lawmakers' hopes for a bipartisan solution. But it's unclear if Congress will help Trump deliver on his promise to repeal the law at any point in the future, although Trump still has time.
For now this promise remains Stalled.
Fox News Sunday transcript, "Conway on White House operations, health care reform," July 30, 2017
Washington Post, "GOP unsure what to do about ACA," July 28, 2017
The Hill, "McConnell: 'Time to move on' after healthcare defeat," July 28, 2017
PolitiFact, "After the health care bill failure, what's next for Congress and the Affordable Care Act?" July 28, 2017u
Vox, "What McCain did was hard. What Murkowski and Collins did was much harder," July 28, 2017
New York Times, "Trump Tells G.O.P. Senators Not to Be 'Total Quitters' on Health Bill," July 29, 2017
AP, "Trump urges GOP not to give up on health bill; Isn't ready to 'move on' after proposal's defeat," July 31, 2017
President Donald Trump expressed disappointment after Republican lawmakers' failure to muster enough votes to repeal Obamacare placed one of his loftiest campaign promises in limbo.
A series of defections by Senate Republicans scuttled two separate efforts to dismantle the sweeping U.S. health care law put in place by Trump's predecessor, President Barack Obama.
"We've had a lot of victories, but we haven't had a victory on health care," Trump told reporters July 18, as it became clear the latest Republican legislative efforts would fail. "We're disappointed."
A slim margin of error constrained GOP efforts to repeal and replace Obamacare and forced a delicate balancing act between the party's conservative and moderate members.
But defections by Sens. Jerry Moran of Kansas and Mike Lee of Utah on July 17 brought to four the number of Republican senators to publicly oppose the bill (along with Susan Collins of Maine and Rand Paul of Kentucky), effectively killing the repeal-and-replace plan. Senate leadership could only afford to lose two Republican votes for passage.
Senate Republicans then turned their attention to a measure that would repeal major parts of Obamacare over two years, in theory buying lawmakers enough time to agree on a replacement plan before the Affordable Care Act, often called Obamacare, was largely dismantled.
That too failed after three Republican senators ― Collins, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska ― said they could not vote to repeal the Affordable Care Act without a replacement plan agreed to in advance.
"I did not come to Washington to hurt people," Capito said in a statement. "I cannot vote to repeal Obamacare without a replacement plan that addresses my concerns and the needs of West Virginians."
Senate Majority Leader Mitch McConnell, R-Ky., conceded he did not have the votes to pass the replacement bill. But he promised there would be a vote on repeal "in the very near future."
However, it remains to be seen whether Republicans will be able to generate the necessary support to repeal the law. For that reason, we're moving our rating of Trump's promise to repeal Obamacare to Stalled.
New York Times, "'Plan C' on Obamacare, Repeal Now and Replace Later, Has Collapsed," July 18, 2017
CNN, "Mitch McConnell's Obamacare repeal plan stalled," July 18, 2017
Just six weeks after House Republicans pulled a bill to substantially overhaul the the nation's health care system, they successfully -- if narrowly -- passed a revised version of the measure.
On May 4, 2017, the House passed a the bill by a 217-213 margin.
Republican leaders adjusted the bill following negotiations with both the conservative and moderate wings of the party.
The revised bill would do several things.
It would end subsidies provided to people who buy health insurance on the Affordable Care Act's online marketplaces, replacing them instead with tax credits. It would repeal several taxes imposed under the ACA that primarily hit high-income taxpayers. It would allow states to obtain waivers to some requirements of the Affordable Care Act, including the "essential health benefits" provision that requires maternity care or mental health services. And it would curb further expansion of Medicaid that had been allowed under the Affordable Care Act, as well as eventually capping Medicaid expenditures in ways that would effectively end its status as an entitlement.
According to the Congressional Budget Office, the original version of the bill would have increased the number of uninsured people by 24 million by 2026. The changes made before passage might change that number, but the specific impact awaits a new score by CBO, which is expected in the coming days.
The bill now moves to the Senate, where it faces an even bigger challenge than it did in the House. If the bill is deemed to require 60 Senate votes for passage -- as many experts expect it will be -- then it may stumble in its present form, since its provisions may not pass muster with a range of moderate Democrats and Republicans whose votes would be needed for passage.
For now, though, Trump's push to pass legislation that would supplant the Affordable Care Act has sprung back to life. We rate it In the Works.
PolitiFact, "PolitiFact's guide to the GOP amendment to health care bill," April 28, 2017
PolitiFact, "Did Paul Ryan flip-flop on how to pass a big health care bill?" May 4, 2017
As a candidate for president, Donald Trump said that "real change begins with immediately repealing and replacing the disaster known as Obamacare."
On March 24, the nation learned that it's not happening immediately. And the road forward isn't clear either.
Capping a frenzied week of negotiations between three House Republican factions -- the party leadership, the hardline conservative House Freedom Caucus, and members of the more moderate, pragmatic wing of the party -- House Speaker Paul Ryan, R-Wis., announced that he would not bring the American Health Care Act to the floor for a vote, as he had planned.
That March 24 announcement came one day after the floor vote had been pushed back to allow for last-minute changes and arm-twisting, and half a day after Trump had issued an ultimatum to House Republicans -- pass the bill or he'll move on.
In the run-up to Ryan's announcement, vote counting by media outlets had concluded that the House GOP would lose too many votes to pass the bill if it tried.
"We came really close today, but we came up short," Ryan said at a press conference. "I will not sugarcoat this. This was a disappointing day for us."
For members on the party's right flank, the American Health Care Act left in place too much of the infrastructure of the Affordable Care Act, President Barack Obama's signature health care law and the target of intense Republican opposition for seven years.
But more moderate Republicans -- especially those serving in Democratic-leaning states and districts -- feared the bill would have taken away insurance from too many Americans. The Congressional Budget Office projected that 24 million more people would be uninsured by 2026 as a result of the bill.
Reconciling the concerns of those two groups proved impossible for Ryan and his team of whips.
Even if the bill had passed the House, it faced rough sledding in the Senate, where several senators were already voicing opposition similar to the House factions. The GOP has only 52 votes in the Senate, meaning that the party could not afford to lose more than two votes either from the right or the center.
It was not immediately clear how congressional Republicans would proceed with efforts to repeal and replace the Affordable Care Act. There is no legislative reason that they could not produce a new bill, but that bill would have to compete with other legislative priorities, such as a tax overhaul or an infrastructure package, for congressional time and attention.
House Minority Leader Nancy Pelosi, D-Calif., called the Republican decision to pull the bill "a victory for the American people." Pelosi was a key player in passing the Affordable Care Act when she served as House Speaker in 2009 and 2010, and her ability to keep a united front among Democrats forced the Republican majority to find enough votes to pass the measure only within its own conference.
As for Trump, he used the bully pulpit to push for the bill, and Ryan thanked him for his efforts as he announced the bill's failure. "The president gave his all in this effort, he did everything he possibly could to help people see the opportunity we had with this bill," Ryan said.
After Ryan's announcement, Trump said from the Oval Office that Obamacare is "exploding now" and he urged Democrats to "get together with us and get a real health care bill." He added that he wants to focus next on tax reform.
Our long-standing policy is to rate promises based on outcomes, not presidential intention. Trump won't be able to repeal Obamacare without direct action from Congress.
With no clear path forward after this major setback, we are moving this promise to Stalled.
Paul Ryan, remarks at a press conference, March 24, 2017
Nancy Pelosi, remarks at a press conference, March 24, 2017
Donald Trump, remarks from the Oval Office, March 24, 2017
On his first day in office, President Donald Trump signed an executive order that gave federal agencies broad authority to defer or delay any part of the Affordable Care Act that costs anybody any money.
More formally, the order tells agencies they can "waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications."
That's a mouthful, but what does it mean, and how far does it go to repeal Obamacare?
Larry Levitt, senior vice-president at the respected and neutral Kaiser Family Foundation, said in a series of tweets that while the impacts are unclear, it shows the administration is "moving to unwind the Affordable Care Act, but it won't be immediate."
Levitt added, "One sure outcome is it creates uncertainty for insurers at a critical time."
Health care analyst Sabrina Corlette at Georgetown University echoed Levitt's point.
"For insurers already uncertain about their future in the Affordable Care markets, the uncertainty this executive order generates doesn't help," Corlette said. "At a minimum they'll have to factor it into their 2018 premiums, which are due to be filed by May 3 in most states."
Robert Laszewski, a health care policy consultant who takes a dim view of Obamacare, said the action raises a host of questions and gives little guidance.
"How will they expect the new Secretary of Health and Human Services and the IRS commissioner, for example, to interpret this?" Laszewski asked. "Just exactly what are they trying to accomplish? Do they only want to make things easier for those in the market, or are they out to just plain blow up Obamacare as soon as possible?"
The reaction from the insurance industry trade group America's Health Insurance Plans has been subdued. The group issued a short statement saying, "We have been meeting with policymakers to offer our recommendations for a better marketplace, and we have found them to be highly engaged and focused on finding real solutions."
Some analysts, including Joe Antos at the market-oriented American Enterprise Institute, see more symbolism than substance in Trump's action. Antos told us that practically speaking, the order doesn't move the ball forward at all toward the goal of repealing the Affordable Care Act. Agencies already had wide latitude on enforcing the law that everyone have insurance or granting states exemptions to Medicaid rules.
"It doesn't create any new authority for any executive branch agency," Antos said. "It basically gives them the instruction to do your job."
The executive order itself only affirms the general policy thrust that everyone understood from Trump's campaign, Antos argued. As far as real change goes, he said, the White House lacks the people to actually green light any specific move.
"They won't have a full team of people until the end of February or even later," Antos said. "When you're operating without a full team, you won't waste time with small stuff anyway. You will focus on what matters most because that is where the money is."
Nicholas Bagley, a law professor at the University of Michigan, posted an assessment that largely agrees with Antos. "For now, the executive order hasn't changed anything," he wrote.
But one element in particular has Bagley worried. The IRS enforces the individual mandate. If the agency plainly states that it won't, insurance mayhem could follow.
"The insurance markets in many states could go into a tailspin," Bagley wrote. "Rates for 2018 will skyrocket, and some insurers could fold."
But that hasn't happened yet.
We continue to rate this promise In the Works.
White House, Executive order on ACA regulations, Jan. 20, 2017
Incidental Economist Blog, Trump's executive order on Obamacare, Jan. 21, 2017
Incidental Economist Blog, Executive actions Trump could take to change the ACA, Jan. 23, 2017
New York Times, What Does Trump's Executive Order Against Obamacare Actually Do?, Jan. 21, 2017
Larry Levitt, tweets, Kaiser Family Foundation, Jan. 21, 2017
Email interview, Sabrina Corlette, program director, Center on Health Insurance Reforms, Georgetown University, Jan. 23, 2017
Email interview, Robert Laszewski, CEO Health Policy and Strategy Associates, Jan. 23, 2017
Email interview, Melinda Buntin, Chair, Department of Health Policy, Vanderbilt University School of Medicine, Jan. 23, 2017
The quest to repeal and replace the Affordable Care Act began even before Donald Trump was sworn in as president.
More than two weeks before Trump's inauguration, the Senate made its first move, approving a procedural motion on Jan. 4 to start debate on a budget resolution.
Passing a budget resolution is a key step in repealing President Barack Obama's signature health care law. It allows the Republican majority in Congress to repeal sweeping portions of the law with just 51 votes in the Senate. This process, known as reconciliation, saves the majority from having to round up the 60 votes required to break a filibuster -- a much tougher challenge.
On Jan. 12, the Senate passed the budget resolution itself, 51-48. Every Democrat voted against it (except for Sen. Dianne Feinstein, D-Calif., who was recuperating from surgery). The only Republican to cross party lines to vote with Democrats was Sen. Rand Paul, R-Ky., who had expressed concerns about repealing the law without a replacement ready to go.
The budget resolution includes instructions that provide the tools necessary to repeal the law.
Among other things, it instructs the Senate Finance Committee and the Senate Health, Education, Labor and Pensions Committee to submit legislation to the Senate Budget Committee by Jan. 27.
The following day, Jan. 13, the House took up the budget resolution, as is required before the reconciliation process can begin. It passed, 227-198, with nine Republicans siding with Democrats and no Democrats siding with Republicans. The resolution directs the House Energy and Commerce Committee and the House Ways and Means Committee to submit legislation to the House Budget Committee by Jan. 27, 2017.
With the budget resolution out of the way, the next step is to draw up an actual reconciliation bill. The reconciliation process is hardly unknown in the context of the health care law: The Democrats used it to pass the ACA in 2010 after they lost their 60-vote Senate margin in a special election.
Still, using reconciliation to repeal the Affordable Care Act has its challenges. While the ACA has a multitude of provisions, the reconciliation process can only address matters related to federal spending and taxes. (The final judgment on what qualifies for inclusion lies with the Senate parliamentarian.)
That means that payment and tax provisions can be rewritten through a reconciliation bill, but other elements of the law not involving the federal budget would have to wait for a separate bill -- one that would almost certainly need to be passed with 60-vote majority.
So it will be much easier for Congress to pick apart the law ("repeal") than enact new legislation ("replace").
Some Republican senators -- including Susan Collins of Maine, Tom Cotton of Arkansas and Paul of Kentucky -- have urged their colleagues to repeal the law only after a credible replacement alternative is ready. Similar sentiment exists in some portions of the House Republican Conference, though the GOP's wider margin in the House make that chamber less of a worry for repeal-and-replace backers than the Senate.
Notably, Trump told the New York Times that he, too, wants a replacement in short order.
"Long to me would be weeks," Trump said. "It won't be repeal and then two years later go in with another plan." Rather, he said, "the 'replace' will be very quickly or simultaneously, very shortly thereafter."
But no such consensus Republican replacement plan has emerged to date, much less a plan that might attract some Democratic support. And getting a credible replacement plan in place by Jan. 27, or even a month or two after that, is considered a heavy lift, given the complexity of the policy task and the fault lines between lawmakers. Some are speculating that the Jan. 27 deadline will be moved.
So House and Senate Republicans have laid the groundwork for repealing at least some of the key tax-and-spending elements of the ACA, but a full "repeal and replace" is much further away and could remain tricky for both procedural and substantive reasons.
Still, this is enough to rate this promise In the Works.
CNN, "Senate Republicans take first step to repeal Obamacare," Jan. 4, 2017
Los Angeles Times, "Republicans take first step to repeal Obamacare, with a long way to go and no clear path," Jan. 12, 2017
CNN, "House takes first step towards repealing Obamacare," Jan. 13, 2017
Politico, "Trump: Quickly repeal and replace Obamacare," Jan. 10, 2017
Politico, "How the GOP plans to repeal Obamacare: A step-by-step primer," Jan. 11, 2017
The Atlantic, "The Limits of Using Reconciliation to Repeal Obamacare," Jan. 13, 2017
Email interview with AshLee Strong, spokeswoman for House Speaker Paul Ryan, Jan. 19, 2017
Email interview with Don Stewart, spokesman for Senate Majority Leader Mitch McConnell, Jan. 19, 2017
Following the Republican playbook, Donald Trump promised as president to repeal the Affordable Care Act and to replace it with something that emphasizes free market principles.
"Real change begins with immediately repealing and replacing the disaster known as Obamacare," Trump said at a Nov. 7, 2016, rally in Michigan.
Currently, 20 million people have health insurance under President Barack Obama's signature law, and the uninsured rate is below 9 percent, a record low. Repealing and replacing Obamacare would require lawmakers to figure out whether they will cover those people, and if so, how.
WHY HE'S PROMISING IT
The Affordable Care Act isn't popular. Polling conducted in 2016 shows that Americans are divided on the law.
And the law has some problems. Despite provisions aimed at curbing rising health care costs, premiums for plans on HealthCare.gov are expected to go up an average of 22 percent in 2017. Insurance companies have pulled out of the marketplaces in 29 states.
HOW MUCH WOULD IT COST
Trump has several policy ideas for what the health care law replacement should include. He suggests allowing providers to sell insurance across state lines, making it so individuals could deduct premium payments from their tax returns and requiring price transparency from health care providers. He also proposes block-granting Medicaid to the states and encouraging health savings accounts.
Trump's proposals could increase the uninsured population by 25 million people and increase the federal deficit by up to $41 billion, according to an independent analysis by the Commonwealth Fund and RAND .
WHAT'S STANDING IN HIS WAY
Republicans have tried and failed dozens of times to dismantle the law in the past. But now with a Republican president and control of both the House and Senate, repealing the law is a more achievable goal.
"It's a pretty high item on our agenda, as you know. And I would be shocked if we didn't move forward to keep our commitment to the American people," said Senate Majority Leader Mitch McConnell at a Nov. 9, 2016, press conference.
However, Republican lawmakers haven't yet figured out exactly what the replacement will look like. They also face the possibility that Democrats will filibuster and block a full repeal.