2017, house republicans tried to reconcile their divisions with the proposed macarthur amendment. the macarthur amendment, developed by representative tom macarthur of the tuesday group (representing more moderate republicans) and representative mark meadows of the house freedom caucus (representing the hard-line right). the language of the proposed amendment became available on april 25, 2017. the amendment allows insurers to charge enrollees in their 50s and early 60s more than younger enrollees. it also allows states to waive essential health benefits and certain sections of the community rating program. as revised by the macarthur amendment, the acha weakens protections for patients with preexisting conditions; under this version of the bill, insurers would be able to charge people significantly more if they had a pre-existing condition. passage in house on may 3, house republicans announced that they had enough votes to pass the bill, after amending it to include an additional $8 billion over five years to subsidize insurance for people with pre-existing conditions. on may 4, 2017, the house of representatives voted in favor of repealing the patient protection and affordable care act and passing the american health care act with a narrow vote of 217 to 213. upon the bill's passing, congressional republicans rushed to the white house for a televised celebration. 217 republican congressmen voted for the bill, while all 193 democrats and 20 republicans voted against it. most of the republicans who voted against the bill are members of the centrist tuesday group, and only one member of the freedom caucus voted against the bill. senate bills the senate developed several amendments / bills to modify the ahca bill that had passed in the house, but none had received enough votes in the senate to pass as of july 28, 2017. these included the: better care reconciliation act of 2017 (bcra), which was not voted on in its initial form, but as modified based on changes led by senator ted cruz, was defeated in a 43–57 vote. obamacare repeal reconciliation act of 2017 (orra), which would have essentially repealed obamacare, and was defeated in a 45–55 vote. health care freedom act of 2017 (hcfa) or "skinny repeal", which would have repealed the individual mandate but not the medicaid expansion, and was defeated in a 49–51 vote. under the various senate bills, the cbo estimated that relative to current law, millions more would be without health insurance and the budget deficit would be reduced moderately (roughly 5% or less over a decade). the effect on insurance premiums would vary widely in the exchange marketplaces (the non-employer market created by obamacare) depending on the specific legislation. better care reconciliation act of 2017 (bcra) in the senate, majority leader mitch mcconnell appointed a group of 13 republican senators to prepare a bill. democrats, independents, and other republicans were excluded from the process and given no information until the new bill was released on june 22, 2017. the senate bill is called the better care reconciliation act of 2017. the bill's differences from the house bill reflected divergent opinions within the republican caucus. the phase-out of the medicaid expansion would be made more gradual, but funding for medicaid as it stood before the aca would be reduced. eligibility for premium subsidies would be tightened for middle-class recipients, but some aid would be extended to enrollees below the poverty level in states that did not expand medicaid. the ahca would have replaced the individual mandate with a provision that would allow an insurer to add a 30 percent surcharge to the premium if an individual goes without coverage for 63 days or more. the original draft of the bcra would have repealed the aca's individual mandate but it did not include the ahca's continuous coverage provision. a few days after the draft's release, it was amended to provide that someone who went without coverage for 63 days or more would have to wait six months to obtain new coverage. obamacare repeal reconciliation act of 2017 (orra) the cbo evaluated the bill, concluding that relative to current law it would reduce the budget deficit by $473 billion over 10 years (roughly 5%), increase the number of uninsured by 17 million in 2018 and 27 million in 2020, and increase average premiums in the marketplaces (non-group/non-employer-based) by roughly 25% in 2018 and by 50% in 2020. roughly half the u.s. population would live in areas with no insurers participating in the marketplaces. health care freedom act of 2017 (hcfa) on july 14, senator john mccain had surgery to remove a blood clot. the next day, mcconnell announced that the vote on proceeding to consider the bill would be deferred until mccain returned from his recuperation period. senate democrats urged the republican leadership to "use this additional time to hold public hearings ... on the policies in the bill, especially the radically conservative cruz/lee proposal released to the public only five days ago." on july 17, senators mike lee (r-ut) and jerry moran (r-ks) came out against the bill, joining rand paul and susan collins who already opposed it, making it impossible for republicans alone to pass it through. it was later revealed that john mccain was diagnosed with brain cancer, which was discovered during his surgery. on july 25, senate republicans released a significantly stripped-down version of the healthcare bill, containing only fundamental provisions of the repeal that all republicans agreed on, designed to only pass the motion to proceed to floor debate, still allowing further amendments to be added on the floor before final passage. the motion to proceed on this version of the bill passed in a 51–50 vote, with a tie-breaking vote cast by vice president mike pence; senators susan collins and lisa murkowski diverged from their party and voted against the measure. senator john mccain traveled to washington for the vote, returning to senate for the first time since his cancer diagnosis. sen. mitch mcconnell amendment called the health care freedom act; also known as "skinny repeal" cbo score of the "skinny bill" after several failed votes within 24 hours of the bill being passed to floor debate, including a repeal without replace bill, the republican senate leadership attempted to pass the health care freedom act (hcfa), referred to as a "skinny repeal." the skinny repeal, which was still being drafted on july 27, only repeals some provisions of the aca, among them the individual mandate, requiring that all americans buy insurance or pay a tax penalty, and parts of the employer mandate, which requires employers with greater than 50 employees to pay for health care for their employees. the bill was brought to the floor vote and the vote reached the predicted 49–50, majority being in favor of keeping the aca as is. a tie would have allowed vice president mike pence to cast a final tie breaking vote. the final vote was to be mccain, who walked to the floor in near silence and held out his hand. in a very climactic moment, he gave a thumbs down and the bill was rejected 49–51, with two other republican senators, susan collins and lisa murkowski, siding with all democrats and independents. graham-cassidy on september 13, 2017, senators graham, cassidy, heller, and johnson released a draft amendment to the bill that "repeals the structure and architecture of obamacare and replaces it with a block grant given annually to states". however, it was not voted upon due to lack of support. on october 12, 2017, due to this failure of congress to pass a repeal, president donald trump issued executive order 13813, titled an executive order to promote healthcare choice and competition. reaction initial version president trump endorsed the bill after its release, calling it "our wonderful new healthcare bill" on twitter. speaker of the house paul ryan referred to the bill as a "conservative wish list" that would provide for "monumental, exciting conservative reform". conservative economist douglas holtz-eakin described the ahca as "a good start". but conservative members of the republican party quickly raised skepticism about the proposed reform as they would prefer a complete repeal of the ppaca. the white house sent mick mulvaney, executive of the office of management and budget, to convince members of the house freedom caucus to support the legislation. according to numerous reports, mulvaney was unsuccessful. shortly after the meeting caucus chairman mark meadows said, "no new position tonight. our position is the same. we believe we need to do a clean repeal bill." a number of conservative groups have also criticized the bill for not being enough of a repeal, calling it "obamacare 2.0". the koch brother-supported organizations americans for prosperity and freedom partners have indicated their intention to put together a multimillion-dollar fund in support of re-election campaigns for conservative lawmakers who take a stand against the bill. the aarp released a statement opposing the bill. stating, "on top of the hefty premium increase for consumers, big drug companies and other special interests get a sweetheart deal". the american medical association released a statement opposing the bill. america's essential hospitals, american hospital association, association of american medical colleges, catholic health association of the united states, children's hospital association, federation of american hospitals, and national association of psychiatric health systems also stated their opposition in a joint letter. conservative groups, including heritage action, the cato institute, americans for prosperity, freedomworks, and the tea party patriots all oppose the bill. progressive groups, including moveon.org, american bridge, the center for american progress, and our revolution, were resolutely opposed to the bill, as expected. economist and the new york times columnist paul krugman stated that the bill's "awfulness is almost surreal", writing that what republican congressional leadership "came up with instead was a dog's breakfast that conservatives are, with some justice, calling obamacare 2.0. but a better designation would be obamacare 0.5, because it's a half-baked plan that accepts the logic and broad outline of the affordable care act while catastrophically weakening key provisions." on march 23, 2017 (the seventh anniversary of aca and one day prior to the vote on the american health care act), former president obama hailed the successes of the affordable care act, including 20 million more americans insured, preexisting conditions covered, young people staying on their parents' plans until 26, lowered costs for women's health care and free preventive care. later versions president trump celebrating the house passage of the american health care act with vice president mike pence and a number of key republicans in the rose garden after the house passed the ahca, but before any legislation passed the senate, republican congressmen gathered with trump to celebrate in the rose garden. in his speech, trump described the bill as "very incredibly well-crafted." republican senators expressed less enthusiasm about the bill and opted to draft their own bill instead of taking up the house's version. congressional democrats and interest groups, such as the aarp, american medical association, aclu, and planned parenthood, expressed their opposition to the bill. at a lunch with senate republicans in june 2017, trump reportedly called the ahca "mean, mean, mean" and a "son of a bitch". he reportedly implored the senators to make their version of the bill "more generous, more kind." later that month, trump confirmed that he had used the term "mean" to describe the bill. on june 16, 2017, a bipartisan group of seven current governors sent a letter to senate majority and minority leaders mitch mcconnell and chuck schumer criticizing the house's legislation and requesting a bipartisan effort in the senate to reform healthcare. the signatories include governors john kasich (ohio), steve bullock (montana), brian sandoval (nevada), john bel edwards (louisiana), john hickenlooper (colorado), charlie baker (massachusetts), and tom wolf (pennsylvania). when the senate bill text (bcra) was released, four conservative republican senators – ted cruz, ron johnson, mike lee, and rand paul – released a joint statement saying that they would not vote for the bill in that form. this was seen as an attempt to move the bill to the right by bringing pressure on mcconnell. the next day, senator dean heller of nevada announced his opposition. he emphasized the effect on medicaid, noting that the bill's cuts to medicaid would "pull the rug" out from under many nevada residents. public opinion an analysis of national polls by mit