WASHINGTON — A formal draft of the House Republican plan to repeal and replace the Affordable Care Act leaked out on Friday.

The final version is likely to be different — how much different, it’s hard to say. The draft obtained by Politico is dated two weeks ago, and rumors have been swirling here that Republicans received an unfavorable analysis from the Congressional Budget Office, the official scorekeepers on the cost and coverage implications of legislation.

But this is nonetheless an important milestone — real legislative text, prepared with an eye toward the complex parliamentary procedures needed to pass ACA repeal with only Republican votes, and presumably with the endorsement of House leadership.


Much attention will be paid to the proposed tax credits offered for people to buy health insurance and the changes to the tax treatment of employer-based insurance. Here are five provisions with big implications for health and medicine.

It would dramatically overhaul Medicaid.

The bill would phase out by 2020 the Medicaid expansion that has covered millions of people under Obamacare. Instead, states would begin to receive a set dollar amount for each person covered by the program — with variations based on health status; more money would be allocated for the disabled — a change from the open-ended entitlement the program is now.

These proposals, long a goal of the GOP, have spurred a number of concerns. People with complex medical needs worry that, if spending is capped and states have more flexibility to decide what to cover, they could be at risk. There appear to be very few exclusions from the spending caps — some have theorized that if the plan exempted certain services from the caps, that could help mitigate the risks for high-cost patients.

The changes could also make it more difficult for the program to afford new breakthrough treatments, a challenge that the current iteration of Medicaid has already faced with the expensive hepatitis C drugs.

It would repeal Obamacare’s requirements for what health insurance must cover.

The legislation would repeal the ACA’s essential health benefits requirements, which mandated that health plans cover 10 categories of health care services. It would instead leave decisions about what coverage to require to the states, starting in 2020.

Among the services that the law required plans to cover were mental health and substance abuse treatment. In the midst of the opioid crisis, recovery advocates in Washington had been hoping to save that provision. It appears that that decision would now be in state officials’ hands, and the fear is plans might look to limit that coverage because people with addiction issues are expensive to treat and therefore cover.

It would repeal the Prevention and Public Health Fund.

The bill would repeal this funding stream, intended to support various prevention and public health activities, in 2019. Congress initially provided $15 billion over the fund’s first 10 years, and it was eventually suppose to increase to $2 billion per year in perpetuity.

The fund has been at perennial risk since its passage in 2010, pilfered at times for other programs, but it nonetheless remains an important source of public health funding. It has become an essential part of the Centers for Disease Control and Prevention’s budget — accounting for 12 percent of the agency’s funding by some estimates — and there would be no obvious replacement for those dollars without further congressional action.

It would repeal the tax on pharmaceutical manufacturers.

The drug industry has not agitated to have its manufacturer tax repealed, in the same way that the medical device and health insurance industries have. But the Republican bill would nonetheless nix the tax starting in 2017. The industry still had $4 billion to left to pay in 2017, $4.1 billion in 2018, and $2.8 billion per year after that.

The taxes on medical devices, health insurance plans, and even tanning beds would also be repealed. Those revenue streams help to cover the cost of the ACA. Republicans are instead proposing changing the tax treatment of employer-based health insurance, which is currently not taxed, to pay for their plan. It is an idea popular with economists, but politically perilous. Major employer groups are already aligning against it.

It loosens restrictions on health plans’ ability to charge older people more.

One thing the bill doesn’t do is repeal the ACA provision that prohibits health plans from discriminating against people with preexisting conditions. That may be because it would be hard to justify under the procedural rules that Republicans need to use to pass the bill — plus that policy is among the law’s most popular elements and even President Trump has said it should be maintained.

But another key insurance reform meant to protect sicker people takes a hit: The GOP bill would allow insurers to charge older people five times more than younger people; the ACA had limited the difference to three times as much. The powerful AARP is already mobilizing against such a change, long expected to be part of the plan.

The bill appears to try to mitigate that change by basing its tax credits for purchasing insurance on age: Older people would receive a bigger tax credit.

Is that sufficient to keep people covered, as Trump and other Republicans have pledged to do? That’s one of the questions that the scorekeepers at the CBO will be expected to answer.

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  • we have the ability to save ssi, ssdi ,medicare ,Medicaid., and cover every man woman and child with equal healthcare . all we need to do is : A. adjust the standard deduction withheld from the net earnings portion of EVERY PERSON earning a wage in the U S of A. NO EXCEPTIONS , no loopholes , no shelters for the wealthy or ways to get around the deduction be reinvesting before taxes are taken .. keep the government out of the private sector and keep the insurance companies , doctors hospitals , and special interests out of legislation .social security has been needing to be overhauled for decades now ,so why not have the treasury department create an internal agency that would combine both since healthcare and social security are really hand in hand all through life! a study could be done ,but I believe that a standard deduction taken out of the gross of every individuals earnings of somewhere between six to eight percent to be withheld in a private department of the treasury and overs sought by the I R S ,with special legislation that no other entity be allowed access to the principle and interest for any reason other than healthcare and social security , [ssdi ,medicare and Medicaid ] ,not even an act of war or a major disaster , monies can not be accessed by any entity , not for any reason as ssi monies were raided in the past we would not be in this position right now. yes it is complicated , but it is not rocket science . the rich need to stop making healthcare and social security look like it is sooo hard because the want to get their hands on the entitlements of the middle class and the poor .and wall street needs to be told to stop eyeing up money they have no right to even look at. social security would be fine ,even have a surplus if politicians were not allowed to raid it like they have in the past . how soon we have forgotten and history will repeat itself if America does not wake up .

    • Where is the equity in only taxing the working for a single payer system? Why would anyone work if they can get SSI, unemployment and health care on the dole. A more reasonable and fair approach is to tax purchases, all purchases. Everyone buys and that way everyone supports the health system.
      As to no input from hospitals and physicians that is a bong dream.

  • We need to vote these narrow minded, short sighted people out of office. They want to build a wall for 25 billion but can’t take care of all Americans. 10% increase in military spending but nearly nothing for us on Social Security.

  • @Bobby….SSI comes with Medicaid. Here in MA its called MassHealth….the most comprehensive MH comes with SSI. As SSI is federal I wld think anyone with SSI receives their state’s medicaid.

    • SSI number is used for many things. Taxes, identification as a citizen for the USA, SSI death benefits, Medicare / Medicaid and the list goes on.
      Unfortunately, not all states are created equal nor value humanity, compassion, or even have a balanced budget. The state I live in a person has to be beyond poor conditions to be on MEDICAID as the State didn’t take the ACA when it was offered because of Obama.
      Now imagine having quality healthcare 24/7 regardless of wage class for yourself, family, friends, and not lose your home or capital as we are all human that needs not want healthcare? More millenials are steering clear from home ownership as College Loans are equivalent to a mortgage without arriving to a quality job to pay the College loan that is also tied to the SSI number that a student can not default on. In Sweden, a student receives free college.
      We The People keep telling ourselves this is the greatest country in Earth yet other countries are far more advanced and you don’t have to lose or borrow for basic human needs nor wait.

  • How about letting consumers decide what health benefits they want their insurance to cover? The idea that my state representatives will mandate the benefits I must have is offensive. Let me decide what I spend my money on.

    • Unfortunately, it would take lots of money to pay the lobbyists who own our State and Federal Congress to pay as you go type healthcare to work.
      Funny, their healthcare is better than ours and free.
      The last part, unless you truly know your DNA codes and what illness or accidents you can predict, let me know. Variables happen and I can tell you Sweden has a great healthcare system while the USA is the only country on Earth that does not provide healthcare to the SSI card holding citizens. Capitalism is over riding the human needs.

  • If these imbeciles get this passed are they going to be covered under the same rules or do they still get lifetime coverage at the taxpayers expense? If not it is long past time for a Constitutional Amendment that Congress shall pass no law the affects the American citizens that does not equally affect them!

    • Well I don’t agree they are idiots but I do think it is only fair that they are subject to the same rules as the rest of us.

  • Wow! The states decide what is funded? The states don’t have a balanced budget nor can pay for teachers or have poor financial ratings.
    This is a train wreck for a rough draft!

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