Track the Key Changes in the GOP’s Health Plan

By Hannah RechtHannah Recht, Zachary TracerZachary Tracer and Mira RojanasakulMira Rojanasakul
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Seven years after the Affordable Care Act was enacted, Republicans are trying to follow through on their promises to repeal and replace Obamacare. On March 6, Republican House leaders introduced their health plan, and Senate Republicans followed with their own bill on June 22.

Senate Republicans are now choosing which of two bills to vote on: a new Obamacare repeal bill introduced on July 19, which is unlikely to pass, and a revised version of their repeal and replace bill.

Congress will need to reconcile differences in the House and Senate proposals before a bill can reach President Donald Trump's desk. We'll track major policy changes and their impacts as Congress drafts and revises legislation to repeal Obamacare.

House bill introduced [March 6] ⟶ First House amendments [March 20] ⟶ House vote canceled [March 24] ⟶ Passes House [May 4] ⟶ Senate bill introduced [June 22] ⟶ Senate revisions [July 20] ⟶ Passes Senate ⟶ House and Senate negotiate and revise bill ⟶ House and Senate pass final bill ⟶ President signs, becomes law
Medicaid Financing
House bill Change
House bill introduced  |  March 6, 2017

Currently, the federal government generally reimburses states for a fixed percentage of Medicaid expenditures, regardless of total spending or number of enrollees. The GOP bill would limit Medicaid reimbursement by a per-enrollee cost, based on 2016 average costs.

House amendment  |  March 20, 2017

Allows states to choose from two formulas for how they get federal Medicaid funding, and boosts the funding for elderly and disabled Medicaid enrollees, relative to the initial bill.

Senate bill Change
Senate bill introduced  |  June 22, 2017

Like the House bill, the Senate bill would allow states to choose between two formulas for federal Medicaid funding. But starting in 2025, the Senate bill would set a lower funding growth rate than the House bill would, meaning states would receive less money. Certain Medicaid enrollees would not be subject to these limits, including people with disabilities and children.

Senate revision  |  July 13, 2017

Hospitals in states with high uninsured rates would receive extra funds, changing how “disproportionate-share” payments are calculated. A new program would help states continue to provide some medical services to Medicaid beneficiaries in their homes, rather than moving them to nursing homes. During a state public health emergency, additional spending would not be subject to the new Medicaid caps.

Budget impact: Under both bills, federal spending on Medicaid would decrease drastically from 2017 to 2026 compared to current law: by $834 billion under the House bill and by $756 billion under the Senate bill. Over time, federal spending would continue to decrease compared to current law and states would have to reduce enrollment or find additional funding sources.

Decrease in Medicaid spending from current law

House

Senate

2018

2026

Source: Congressional Budget Office
Medicaid Expansion
House bill Repeal
House bill introduced  |  March 6, 2017

The ACA allowed states to expand Medicaid to individuals making as much as 138 percent of the federal poverty level, with federal funding. The GOP bill winds down Obamacare's Medicaid expansion starting in 2020.

House amendment  |  March 20, 2017

Won't provide extra funding to states that newly expand Medicaid.

Senate bill Repeal
Senate bill introduced  |  June 22, 2017

Medicaid expansion funding would be phased out between 2021 and 2024.

Human impact: In both bills, Medicaid enrollment would decrease rapidly over the next decade. Compared to current law, 14 million less people would be covered by Medicaid in 2026 under the House bill and 15 million under the Senate bill.

Decrease in Medicaid enrollment from current law

House

Senate

0M

–3

–6

–9

–12

–15

Source: Congressional Budget Office
Insurance Mandates
House bill Repeal
House bill introduced  |  March 6, 2017

The House bill ends Obamacare's requirement that individuals have health coverage and that most employers offer it. Instead, when people who've gone uninsured decide to buy health insurance, they'll have to pay a 30 percent surcharge on their premiums for one year.

Senate bill Repeal
Senate bill introduced  |  June 22, 2017

The Senate bill ends Obamacare's requirement that individuals have health coverage and that most employers offer it.

Senate revision  |  June 26, 2017

To replace Obamacare's mandate, the Senate bill would impose a six-month waiting period before new insurance goes into effect for anyone who had a break in coverage of at least 63 days in the prior year. The provision takes effect in 2019.

Human impact: People who lose coverage and then want to purchase insurance again would face increased costs under the House bill, or remain uninsured during the added six-month waiting period under the Senate bill.

Budget impact: Revenue loss of $210 billion from 2017 to 2026 from repealing insurance penalties.

Source: Congressional Budget Office
Premium Subsidies
House bill Change
House bill introduced  |  March 6, 2017

The ACA introduced subsidies based on income and the cost of health insurance, with some help available to people making up to 400 percent of the poverty level, or about $47,000 for an individual. The House bill would base subsidies mainly on age, phasing out funding beginning at an income of $75,000 for an individual.

Senate bill Change
Senate bill introduced  |  June 22, 2017

The Senate bill would maintain the ACA's subsidies through 2019, but change how subsidies are allocated starting in 2020. The ACA calculates subsidies based on a mid-level coverage plan, while the Senate bill would use a cheaper type of plan. Subsidies would no longer be available to those above 350 percent of the poverty level, or about $42,000 for an individual.

Senate revision  |  July 13, 2017

The Affordable Care Act allowed marketplace insurers to sell low-cost catastrophic plans, which have high deductibles and restrict eligibility to young adults and people with financial hardships. The Senate revision would allow anyone to purchase these plans and make them newly eligible for subsidies.

Human impact: Many low-income subsidy recipients would lose thousands in premium subsidies, particularly older enrollees in higher-cost areas. In the House bill, some people who currently earn too much to qualify for subsidies would receive new assistance. The Senate bill does not offer similar assistance. Instead, it would place additional limits on who qualifies for subsidy assistance, making some middle-class recipients who currently receive subsidies ineligible.

Budget impact: From 2017 to 2026, federal spending on premium subsidies would fall by $276 billion under the House bill and by $396 billion under the Senate bill.

Source: Congressional Budget Office
Essential Health Benefits
House bill Change
House amendment  |  March 23, 2017

The ACA requires health insurance plans to cover 10 broad categories of essential health benefits, as well as to provide preventive services at no cost. The bill initially left the requirement intact, but an amendment that would repeal that requirement was added. Instead, states will define their own list of benefits that are required for plans receiving premium subsidies beginning Jan. 1, 2018.

House amendment  |  May 3, 2017

An amendment was added that would leave essential health benefits intact—reinstating the federal standard. Instead, states could opt out of the requirement and apply for a waiver to define their own list of benefits that are required for plans receiving premium subsidies beginning Jan. 1, 2020.

Senate bill Change
Senate bill introduced  |  June 22, 2017

Senate bill adopts changes in House bill.

Senate revision  |  July 13, 2017

An amendment backed by Senators Ted Cruz and Mike Lee would provide insurers broad latitude to sell individual insurance plans that don't comply with Obamacare's mandates. To do so, they'd have to also offer subsidy-eligible Obamacare plans on the marketplaces.

Human impact: The Congressional Budget Office expects that half of the U.S. population live in states that would waive some required benefits. Plans in these states would likely have lower premiums, but they would cover less. For instance, maternity care premiums could cost an additional $1,000 per month or more. Customers seeking comprehensive coverage could face premiums and out-of-pocket charges that are significantly higher than under current law.

Budget impact: Insurers in some states could offer plans with such limited coverage that CBO does not consider them health insurance. Those plans would still be eligible for millions of dollars in federal subsidies.

Source: Congressional Budget Office
Pre-existing Conditions
House bill Change
House amendment  |  May 3, 2017

The ACA requires health insurers to sell plans to individuals who are sick with so-called pre-existing conditions and not charge them more than healthy customers. An amendment would allow states to apply for a waiver that would let insurers charge higher premiums to people with pre-existing conditions that had a gap in coverage of at least 63 days in the prior year. To do so, states would have to establish some method (a special “high-risk” insurance pool, or subsidies) to help sick people.

Senate bill No Change
Senate bill introduced  |  June 22, 2017

Insurance companies would not be allowed to charge customers with pre-existing conditions more than healthy customers.

Human impact: In states that allow insurers to charge people with pre-existing conditions more than healthy people, those less healthy individuals would face increasingly prohibitive premiums under the House bill. Eventually, the CBO predicts, less-healthy people may not be able to afford any coverage.

Source: Congressional Budget Office
Age Rating
House bill Change
House bill introduced  |  March 6, 2017

Obamacare lets health insurers charge their oldest customers no more than three times as much as their youngest ones. The GOP bill introduced widens the ratio to 5 to 1.

House amendment  |  March 20, 2017

Adds a provision that would let the Senate decide whether to increase subsidies that go to older Americans.

House amendment  |  May 3, 2017

Adds a provision that would allow states to apply for a waiver to give insurers permission to charge older customers even more than the 5 to 1 ratio.

Senate bill Change
Senate bill introduced  |  June 22, 2017

Senate bill adopts changes in House bill.

Human impact: Premiums would significantly rise for older people and decrease for younger people. Low-income older adults would face much higher premiums than under current law, even with federal subsidies.

Source: Congressional Budget Office
State Grants
House bill New
House bill introduced  |  March 6, 2017

Includes a new $100 billion fund designed to help states stabilize their individual health insurance markets or help low-income people get health care.

House amendment  |  March 23, 2017

Adds $15 billion to the fund to be used for maternity, newborn, mental health and substance abuse coverage.

House amendment  |  April 6, 2017

Adds $15 billion for the Federal Invisible Risk Sharing Program, designed to help insurers cover the costs of sick and expensive patients.

House amendment  |  May 3, 2017

Adds $8 billion in funding from 2018 through 2023 to help individuals afford higher premiums in states that let insurers charge sick people more.

Senate bill New
Senate bill introduced  |  June 22, 2017

The Senate bill would include $112 billion in state grant funds, primarily to stabilize state insurance markets and cover expensive patients. It would also allocate $2 billion in 2018 for substance abuse treatment.

Senate revision  |  July 13, 2017

The Senate revision would add an additional $70 billion for market stabilization and $45 billion in grants to states toward combating the opioid crisis. A share of the grant funds would be earmarked for states with very high premiums—based on 2017 data from the Centers for Medicare and Medicaid, Alaska is the only state that would qualify.

Human impact: Under the Senate bill, CBO expects that most of the funds would go towards lowering premiums in the individual market for people not eligible for subsidies. Some funding would also be available to help people with pre-existing conditions, but it would not be enough to significantly lower their costs.

Budget impact: Both bills would require more than $100 billion in additional federal spending.

Source: Congressional Budget Office
Medicaid Work Requirements
House bill New
House amendment  |  March 20, 2017

Gives states the option of requiring some Medicaid recipients to work or pursue job training.

Senate bill New
Senate bill introduced  |  June 22, 2017

Senate bill adopts changes in House bill.

Human impact: According to the Kaiser Family Foundation, 10 million non-elderly adult Medicaid recipients who don't receive Social Security are not working. Some of these adults would be excluded from work requirements due to disability, pregnancy or caretaker status, but many would be expected to complete job training or find employment in order to keep their insurance.

Source: Kaiser Family Foundation
Planned Parenthood and Abortion Care
House bill New
House bill introduced  |  March 6, 2017

Ends all federal funding for Planned Parenthood for one year. The bill also prohibits federal funds from going to insurance plans that cover abortions, other than those necessary to save the life of the woman, or in cases of rape or incest.

House amendment  |  March 20, 2017

Adds additional safeguards to prevent government funds from being used for some abortions.

Senate bill New
Senate bill introduced  |  June 22, 2017

Senate bill adopts changes in House bill.

Human impact: Several thousand Medicaid-covered births would occur because of the loss of Planned Parenthood contraceptive and abortion care, particularly among women in areas without other providers that serve low-income patients.

Budget impact: Direct spending would decrease by $225 million between 2017 and 2026 under the Senate bill, but new births due to the Planned Parenthood provision would increase Medicaid spending by $79 million over the same period.

Source: Congressional Budget Office
Individual Taxes
House bill Repeal
House bill introduced  |  March 6, 2017

Repeals a 0.9 percent Medicare payroll surtax and a 3.8 percent investment-income tax on wealthy individuals that were introduced in the ACA, effective 2018.

House amendment  |  March 20, 2017

Ends the taxes in 2017, rather than 2018.

House amendment  |  March 23, 2017

Postpones repeal of the additional Medicare tax to 2023.

Senate bill No change
Senate bill introduced  |  June 22, 2017

Senate bill adopts the tax repeals in House bill.

Senate revision  |  July 13, 2017

Keeps both the 0.9 percent Medicare payroll surtax and the 3.8 percent investment-income tax on wealthy individuals. Allows the purchase of health insurance with funds from a health savings account, which provides tax advantages.

Human impact: Under the House bill, wealthy individuals would get a tax break. In counties that backed Trump, taxpayers would save $6.6 billion, while taxpayers in Clinton counties would save $21.6 billion.

Budget impact: From 2017 to 2026, the repeal would lose $172 billion in Net Investment Tax revenue and $59 billion in Medicare tax revenue from 2023 to 2026.

Source: Congressional Budget Office
Industry Taxes
House bill Repeal
House bill introduced  |  March 6, 2017

Repeals ACA taxes imposed on health insurers, pharmaceutical companies, medical-device companies and tanning salons, effective 2018.

House amendment  |  March 20, 2017

Ends the taxes in 2017, rather than 2018.

Senate bill Repeal
Senate bill introduced  |  June 22, 2017

Repeals most taxes immediately. A tax on providers would be phased out in 2025.

Budget impact: Loss of about $200 billion in tax revenue from 2017 to 2026.

Tax revenue lost, 2017–2026
Source: Congressional Budget Office
Cadillac Tax
House bill Change
House bill introduced  |  March 6, 2017

Obamacare imposes a tax on very generous health insurance benefits, which was delayed to 2020. The bill introduced further pushes the tax back to 2025.

House amendment  |  March 20, 2017

Delays the tax to 2026.

Senate bill Change
Senate bill introduced  |  June 22, 2017

Senate bill adopts changes in House bill.

Budget impact: Loss of $66 billion in tax revenue through 2026.

Tax revenue lost

$0B

–3

–6

–9

–12

–15

Source: Congressional Budget Office
Dependent Coverage
No proposed change to current law

The ACA requires health insurers to allow children to remain on their parents' plans, up to age 26.