cbo reported that the health exchange marketplaces would remain stable (i.e., no "death spiral"). yale law school professor abbe r. gluck, the director of the solomon center for health law and policy, writes that republican elected officials have taken a variety of steps to "sabotage" the aca, creating uncertainty that has likely adversely impacted enrollment and insurer participation, and then insisting that the exchanges are in difficulty as an argument for repealing the aca. the washington post columnist dana milbank has made the same argument. health insurance writer louise norris states that republicans sabotaged the aca through: lawsuits, both successful (medicaid expansion limited) and unsuccessful (mandates and insurance subsidies upheld). lawsuits pending, such as whether cost-sharing subsidies must be paid. president trump is threatening not to pay these subsidies. prevention of appropriations for transitional financing ("risk corridors") to steady insurance markets, resulting in the bankruptcy of many co-ops offering insurance. weakening of the individual mandate through irs-related executive orders to limit penalty collection. reduction to funding for advertising for the 2017 exchange enrollment period. ongoing insistence, despite cbo assertions to the contrary, that the exchanges are unstable or in a "death spiral". other impact social security expenditures would decrease due to earlier mortality: "cbo also estimates that outlays for social security benefits would decrease by about $3 billion over the 2017–2026 period." medicaid expenditures would increase due to reduced access to birth control. "by cbo's estimates, in the one-year period in which federal funds for planned parenthood would be prohibited under the legislation, the number of births in the medicaid program would increase by several thousand, increasing direct spending for medicaid by $21 million in 2017 and by $77 million over the 2017–2026 period." two reports from the center for budget and policy priorities concluded that the acha would have shifted $370 billion in medicaid costs to the states, which would have then been forced to cut coverage and services, and would make health insurance far less affordable in high-cost states, particularly 11 states in which tax credit would have been more the halved. every year one in 830 uninsured americans die in a way which could have been prevented with better health care. a congressional budget office report suggests an extra 16 million people would be left uninsured leading to 19,277 preventable deaths. other uninsured people would develop painful chronic conditions or permanent disabilities which could have been prevented with health insurance. other provisions the bills would allow states to continue to enroll persons in the aca medicaid expansion through january 1, 2020, and would disallow further enrollment after that date. the ahca will include age-based tax credits for those who earn less than $75,000, or $150,000 for joint filers. the bill would have required insurance companies to cover pre-existing conditions. the ahca used a standard of 'continuous coverage', defined by a 63-day coverage gap, where an individual who currently has insurance and is changing insurers will not pay a higher rate with their new insurer. individuals who wished to buy insurance but were outside of the coverage gap would have paid a 30 percent premium surcharge for one year and then return to standard rates. both healthy and the sick were required to pay the surcharge, which may have caused healthier persons to remain outside of the market, causing overall health care costs to rise (see adverse selection, high-risk pool). accuracy of cbo coverage forecasts in general, cbo has been more accurate than other significant forecasting entities regarding the coverage impact of the aca/obamacare. it has been very accurate with respect to forecasting the number of uninsured and change in uninsured, but off significantly in forecasting the number of persons who would enroll in the exchanges. instead, many more persons retained their employer-based plan than cbo had anticipated. cbo revises its forecasts for health insurance coverage due to current law (aca/obamacare) annually. cbo forecast in february 2010 that there would be 31 million fewer uninsured in 2017 due to aca; the 2016 forecast for 2017 was 24 million (7 million or 23% difference). the kaiser family foundation estimated in october 2015 that 3.1 million additional people were not covered because of 19 states that rejected the medicaid expansion in the wake of a 2012 supreme court decision that preserved their existing medicaid funding whether or not they expanded coverage. this 2012 event accounts for much of the difference; cbo reduced its medicaid coverage expansion forecast for the year 2017 by 5 million between 2010 and 2013. cbo forecast in february 2013 that there would be 29 million uninsured in 2017; the 2017 forecast is 27 million (2 million or 7% difference). cbo forecast in february 2013 that there would be 11 million additional persons covered by medicaid in 2017; the 2017 forecast is 12 million (1 million or 9% difference). cbo forecast in february 2013 that there would be 26 million additional persons covered under the exchanges in 2017; the 2017 forecast is 10 million (16 million or 62% difference). regarding the inaccuracy of their exchange forecast, cbo explained that one of their assumptions was that more employers would choose to drop their coverage in favor of the exchanges than has actually occurred. cbo wrote in march 2017 that: "...most of the people who are no longer projected to obtain insurance through the marketplaces will instead be covered by employment-based insurance." history trump discussing with lawmakers on replacing the aca at the white house, march 2017. initial version the two bills that constituted the ahca were introduced into the house energy and commerce committee and the house ways and means committee on march 8, 2017 and passed both committees the next day. both committees approved the ahca on a party-line vote without a cbo report, prompting criticism from democrats. house minority leader nancy pelosi argued that the bill should not proceed through congress until the cbo completed its analysis of the bill. representative richard neal, the ranking democratic member of the house ways and means committee, stated: "to consider a bill of this magnitude without a cbo score is not only puzzling and concerning, but also irresponsible." trump administration officials, including budget director mick mulvaney and economic adviser gary cohn, preemptively attacked the cbo, with cohn saying that the cbo's score would be "meaningless". these criticisms from the white house are unusual: prior administrations of both parties had refrained from questioning the cbo's credibility, and many members of congress respect the cbo as a neutral body. the bill next went to the house budget committee, which passed it on march 16 by 19 to 17 votes, with three republicans from the conservative freedom caucus joining democrats in opposition. it next went to the rules committee, which sets the terms of the debate before a bill comes to the full house. a house vote was initially scheduled for march 23, but was delayed for at least a day after republican leaders were unable to find enough votes for passage. on march 24, with both moderate and far-right republican lawmakers opposing the bill, speaker paul ryan and president trump chose to withdraw the bill from consideration rather than go through with a full house vote that would have failed. the comparatively "lightning fast" legislative movement for the ahca through the house was in contrast to the affordable care act, which took months of negotiations, committee markup, and debate before passage in 2010. the quick process prompted complaints from democrats "that the republicans were rushing to approve a repeal bill without hearing from consumers, health care providers, insurance companies or state officials – and without having estimates of the cost or the impact on coverage from the congressional budget office". in house committees, democratic representatives offered more than 100 amendments to the legislation, including amendments that "would have required the law to guarantee no one would lose insurance, hospitals would not see an increase in uncompensated care, the deficit would not increase, taxes would not go up on people making less than $250,000, and that people over 55 years old would not lose benefits or pay higher out-of-pocket costs." democratic representative joe crowley of new york offered an amendment that during the 2010 affordable care act debate had been proposed by republican representative kevin brady of texas, requiring "that the bill be posted online for 72 hours before any votes were taken on it, and that every member put a statement in the congressional record stating he or she had read the bill." all of these democratic amendments were rejected, as brady (the chairman of the house ways and means committee) ruled that the amendments were "not germane" to the bill, and the republican majority repeatedly upheld these rulings. division among house republicans in the days leading up to the vote, which was originally scheduled for march 23, 2017, there was increased division among house republicans over the replacement, causing concerns among republican party leadership over having the votes needed to pass the bill. among republican defectors from the bill, the largest opposition came from members of the house freedom caucus, which consists of some of the most conservative members in the house. the freedom caucus members, among their primary objections to the bill, were not convinced that the healthcare replacement effectively abolished some elements of the affordable care act, most prominently the essential health benefits. to achieve success in the house, republicans could not afford more than twenty-one members of their own party voting against the bill, and several days before the vote, dissent within the party, largely from the freedom caucus, was a significant threat to its passage. beyond the conservative members of the freedom caucus, there was continued opposition to the bill from more moderate republicans in the house, such as from members of the center-right tuesday group, where there were concerns about loss of coverage and the potential of rising insurance costs. amid the division between the republicans, the party leadership, which was led by house speaker paul ryan, attempted to ease concerns among the freedom caucus and others. president trump also held numerous meetings with republicans in the house leading up to the vote, though after negotiations with the freedom caucus over the aca's essential health benefits, there was still a considerable amount of opposition from moderates and members of the freedom caucus alike. on the day of the scheduled vote, which coincided with the seven-year anniversary of the aca's signing into law, party leadership continued to struggle with getting the required votes for the bill, and the vote was rescheduled for the following day, march 24, 2017, as requested by the white house. withdrawal ahead of vote the night before the rescheduled vote, trump, in a final effort to negotiate with those opposing the bill, announced to the house republicans that the vote the following day would be their only chance to repeal the affordable care act, a goal long sought after by republicans in congress. the following morning the bill was brought to the house floor after being approved by the house rules committee for four hours of debate preceding the vote, which was expected in the afternoon. it was reported that a couple hours before the expected vote, ryan made a sudden visit to the white house to meet with trump, in which ryan told trump that the bill did not have enough votes to pass in the house. shortly after the time of the expected vote it was announced that the republicans were withdrawing the ahca from consideration, a decision made after ryan met with trump. following the withdrawal, ryan stated in a press conference that the country is "going to be living with obamacare for the foreseeable future", while trump said that it was tough to pass the bill without support from democrats; ryan and trump both said they were going to move forward on other policy issues. revised version through the various iterations of bill it has been nicknamed variously as trumpcare, ryancare, republicare, and pejoratively as obamacare-lite, and wealthcare. map of the house of representatives' vote on h.r. 1628, the "american health care act of 2017", on may 4, 2017 (sorted by whoever represents each congressional district): 217 yes (republican) 20 no (republican) 1 not voting (republican) 4 vacant seat 193 no (democrat) macarthur amendment in april