House Republican leaders' inability to get an Affordable Care Act change bill to theHouse floor today could increase the likelihood that the ACA willsurvive in its current form, or that Democrats and Republicans willhave to work together to develop a bipartisan replacement.

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House leaders had planned to get some version of H.R. 1628, the American Health Care Act bill,up on the floor for a vote today.

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Instead, lengthy negotiations between House leaders and membersof the Freedom Caucus, a House Republican group,pushed Republican leaders to put the House in recess. At presstime, House members who wanted to vote had stay close to the House,because resumption of proceedings was "subject to the call ofthe chair," and could happen at any time from press time untilMonday.

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President Donald Trump said he wants the House to vote on thebill Friday. Politico is reporting that he is open to leaving theACA in place, at least for now.

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Before the House recessed, members debated HouseResolution 221, a measure that would let House leaders suspendthe normal bill consideration rules using a provision that criticsjokingly describe as "martial law." The martial law rule, which hasnothing to do with military rule of the country, lets Houseleaders unveil a bill between now and Monday and have members voteon the bill the same day, rather than giving members a few days toreview the bill.

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Members of the House Rules Committee voted 9 to 3 to approve themartial law resolution late Wednesday.

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Rep. Alcee Hastings, D-Fla., said at the House Rules meeting onWednesday, which was streamed live on the web, that Republicanleaders had asked for the resolution to get time to "buy morevotes."

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Rep. Pete Sessions, R-Texas, the House Rules chairman, lookedfrustrated. He told Democratic members he wished he could give themmore information about what was going on, but that he had been toobusy to do more than monitor "the Republican conference maneuvershappening via press."

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House Rules has posted videorecordings of the proceedings here.

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Sessions defend the martial law rule on the House floor thismorning. He said the process will produce a good bill.

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"We will own it, and we will be proud of it," Sessions said.

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Rep. Jim McGovern, D-Mass., blasted the rushed process.

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"Are Republicans seriously contemplating making a change of thismassive without hearing?" McGovern asked. "With no chance to readthe bill?"

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The House chair ruled that members had approved the martial lawrule by voice vote, but the chair then approved a motion for arecorded vote. The House went into recess before it could hold arecorded vote on the martial law resolution.

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[UPDATE: As of 8:15 p.m. March 23, House memberswere back in business and voting on the martial lawresolution.]

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Later in the day, the Congressional Budget Office posted ananalysis of a version of H.R. 1628 that would include key proposedamendments. The CBO analysts ruled that the revised bill wouldnarrow the federal deficit by just $150 billion over 10 years,rather than by $337 billion, under the original public version ofH.R. 1628.

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Many lawmakers, including Republicans, have said that they areunhappy with the CBO prediction that the original public version ofH.R. 1628 could increase the number of uninsured people by 24million by 2026, mainly by decreasing Medicaid enrollment.

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In the new analysis, which is available here, the CBO says theproposed H.R. 1628 revision and the earlier version would leaveroughly the same number of people without health coverage.

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Rep. Jared Polis, D-Colo., said Wednesday during House Rules meeting that he'd like to work on bipartisan ACA changes. (Photo: House Rules)
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Rep. Jared Polis, D-Colo., said Wednesday during House Rulesmeeting that he'd like to work on bipartisan ACA changes. (Photo:Polis)

Process

The Republicans hold just 237 seats in the House and expect toneed 216 votes to pass H.R. 1628 there.

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Republicans hold 52 seats in the Senate. Under traditionalSenate rules, they need 51 votes there to pass a "budgetreconciliation" measure, and 60 votes to pass an ordinary bill. TheSenate parliamentarian, an obscure advisor hired by the Senatemajority leader, decides which provisions are "germane" to thebudget and can be included in budget reconciliation.

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To comply with the traditional Senate rules, Republican leaderscrafted H.R. 1628 as a budget measure. Because of those rules, H.R.1628 would eliminate or change many ACA taxes, such as the tanningsalon tax. The bill also would change the current income-basedpremium tax credit subsidy to an age-based subsidy available tomore people. The bill would not affect ACA provisions that clearlyhave no direct effect on federal spending, such asthe essential health benefits package.

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The EHB package is supposed to ensure that individual andsmall-group major medical coverage is solid coverage, and helpconsumers compare individual and small-group coverage on anapples-to-apples basis. The provision requires issuers, in mostcases, to cover at least about 60 percent of the actuarial value of10 types of care, such as hospital care and physician services. TheU.S. Department of Health and Human Services has ruled that the EHBpackage must include coverage for mental health and substance abuseservices.

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Members of the Freedom Caucus, a House Republican group, havebeen pushing for a full ACA repeal bill, or, at least, a bill thatwould eliminate ACA provisions such as the EHB provision.

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The EHB package requirement did not exist before 2010, but theidea of eliminating it has drawn harsh criticism. MargotSanger-Katz, a New York Times reporter, quoted a health caremanagement professor who said the change could produce a plan thatwould "cover aromatherapy but not chemotherapy."

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Some Republicans, including Sen. Ted Cruz, R-Texas, that VicePresident Mike Pence has the authority to shape the budgetreconciliation process, and that Republicans should be able to usethat authority to get a full ACA repeal-and-replace bill throughthe Senate with 51 votes.

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But another problem is that an ACA bill that appeals to FreedomCaucus might not be able to win support from Senate Republicanssuch as Susan Collins of Maine and Dean Heller of Nevada.

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A bill that's too liberal to appeal to the Freedom Caucus mightlose the votes of some Senate Republicans, such as Cruz and RandPaul.

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In theory, more moderate Republicans and Democrats, suchas Collins, Heller and Sen. Chuck Schumer, D-N.Y., could teamup to come up with a bipartisan ACA change bill.

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Rep. Jared Polis, D-Colo., said he's still hoping for abipartisan ACA change effort Wednesday, during the House Rulesmeeting. He said and many colleagues had been eager to push for ACAchanges for years and would like to work with Republicans on abill.

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One challenge is that health insurers are preparing filings forthe 2018 market now and need to know what the rules will be lastmonth.

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Another challenge is that the calendar affects budget measuresand ordinary bills differently, according to James Slotnick, agovernment relations executive at Wellesley Hills,Massachusetts-based U.S. arm of Sun Life Financial Inc.

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Lawmakers could introduce a bipartisan ACA change bill at anytime during the session.

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If, however, Republican lawmakers want to use one budget measurefor changing the ACA, and one for tax reform, then they mustcomplete work on the ACA-changing measure by April 28, before theend of the 2016 budget window, Slotnick writes in an analysis ofthe process.

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"Once the 2017 budget window opens, Republicans will try to usebudget reconciliation to move individual tax reform though theSenate," Slotnick writes.

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Allison Bell

Allison Bell, ThinkAdvisor's insurance editor, previously was LifeHealthPro's health insurance editor. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached at [email protected] or on Twitter at @Think_Allison.