AHCA meets BCRA; timeline, context, and future directions.

IntRoduCtIon This past decade has brought important change to the delivery of healthcare in the United States. In 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA, also referred to as ACA or Obamacare) into law. The ACA sought to provide insurance for millions of additional Americans while simultaneously bending the cost curve down. Beyond that, the far-ranging law imposed new taxes, developed new independent agencies with heightened power in shaping healthcare policy and regulations, and advanced the implementation of accountable care. In response to the Congressional vote passing the ACA along strict party lines, Republicans have repeatedly emphasized their desire to undo the legislation and replace it with something they considered better. The Republican Congress subsequently undertook multiple votes to repeal the ACA throughout the remainder of the Obama administration. Nonetheless, even if successful in passing Congress, all such efforts were guaranteed to be vetoed by the President. In January 2015, Secretary of Health and Human Services Sylvia Burwell described the administration’s priority of transitioning volume-based care to a system providing greater value, 7 and a whole new industry was formed to manage this transition. 9 Throughout this period, a legion of other regulatory issues was confronting healthcare practitioners, ranging from ICD-10 implementation to meaningful use. One such perennial issue was the need to implement a fix to prevent enormous cuts to Medicare payments resulting from the sustainable growth rate formula for Part B services. 12 In April 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed, permanently ending the sustainable growth rate. 14 However, MACRA, which has been described in numerous dedicated reviews, 16 introduced an array of new challenges for providers, beneficiaries, and payers alike. 18 It is generally agreed that there are challenges to the continued vitality of the ACA. Of particular note, working and middle class people who earn more than 400% over the poverty level are not eligible for the federal cost sharing subsidies and face potentially dramatic insurance premium increases. The exchanges that were established in order to support individual healthcare insurance have not enjoyed the type of success that the legislation’s authors anticipated. Further, the employer mandates associated with the ACA have contributed to the estimated 6 million people who have lost healthcare insurance. However, the proposed paths to fixing it differ widely. Many Democrats believe the existing framework of the ACA could be improved by further government intervention to mitigate challenges faced by insurance carriers in providing coverage for pre-existing conditions in the insurance exchanges; whereas many Republicans favor ACA repeal with replacement legislation and generally less federal intervention. November 2016 drastically changed the political landscape as the executive branch and both chambers of Congress were now led by Republicans. Healthcare quickly became the priority. A previous review in JNIS detailed the intricacies of the initial ACA repeal legislation passed by the House—namely, the American Healthcare Act (AHCA). Using the timeline format established by the UCSF/UC Hastings Consortium on Law, Science and Health Policy, that manuscript will be updated here.