Legislative Actions to Repeal, Defund, or
Delay the Affordable Care Act

C. Stephen Redhead
Specialist in Health Policy
Janet Kinzer
Information Research Specialist
July 8, 2015
Congressional Research Service
7-5700
www.crs.gov
R43289


Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act

Contents
Introduction ...................................................................................................................................... 1
A Brief Overview of the ACA ......................................................................................................... 1
ACA’s Impact on Federal Spending ................................................................................................. 3
Mandatory Spending on Expanding Insurance Coverage ......................................................... 3
Mandatory Spending on Other Programs .................................................................................. 3
Discretionary Spending ............................................................................................................. 4
ACA Provisions in Authorization Legislation ................................................................................. 5

Tables
Table 1. Enacted Legislation That Modified, or Extended or Rescinded Funding for,
Programs Established by the ACA ............................................................................................... 7
Table 2. ACA Provisions in Bills Approved by the House in the 112th, 113th, and 114th
Congresses .................................................................................................................................. 10

Contacts
Author Contact Information........................................................................................................... 16

Congressional Research Service

Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act

Introduction
Congress remains deeply divided over implementation of the Patient Protection and Affordable
Care Act (ACA), the health reform law enacted in March 2010.1 Since the ACA’s enactment,
lawmakers opposed to specific provisions in the ACA or the entire law have repeatedly debated
its implementation and considered bills to repeal, defund, delay, or otherwise amend the law.
To date, most of this legislative activity has taken place in the House, which reverted to
Republican control in 2011. Over the past four years the Republican-led House has passed
numerous ACA-related bills, including legislation that would repeal the entire law. There has
been far less debate in the Senate, which remained under Democratic control through 2014. Most
of the ACA legislation that passed the House during this period was not considered in the Senate.
However, a few bills to amend specific elements of the ACA that attracted sufficiently broad and
bipartisan support were approved by both the House and the Senate and signed into law. Now that
Republicans control both chambers of Congress, opponents of the ACA see new opportunities to
pass and send to the President legislation that would change the law.
This report summarizes legislative actions taken to repeal, defund, delay, or otherwise amend the
ACA since it was signed into law. The information is presented in Table 1 and Table 2. While a
detailed examination of the ACA itself is beyond the scope of this report, a brief overview of the
ACA’s core provisions and its impact on federal spending is provided as context for the material
in the tables.2 This report is updated periodically to reflect legislative and other developments.
In addition to considering ACA repeal or amendment in authorizing legislation, some lawmakers
have used the annual appropriations process in an effort to eliminate funding for the ACA’s
implementation and address other concerns they have with the law. A companion report, CRS
Report R44100, Use of the Annual Appropriations Process to Block Implementation of the
Affordable Care Act (FY2011-FY2016)
, summarizes the ACA-related language added to annual
appropriations legislation by congressional appropriators since the ACA was signed into law.
A Brief Overview of the ACA
The ACA made significant changes to the way U.S. health care is financed, organized, and
delivered. Its primary goal is to increase access to affordable health care for the medically
uninsured and underinsured. To that end, the law included a complex set of interconnected
provisions that address the private health insurance market.

1 The ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the
President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029). HCERA
included several new health reform provisions and amended numerous provisions in the ACA. Several subsequently
enacted bills made additional changes to selected ACA provisions. All references to the ACA in this report refer
collectively to the law and to the changes made by HCERA and subsequent legislation.
2 Numerous CRS products that provide more in-depth information on the many new programs and activities authorized
and funded by the ACA are available at http://www.crs.gov/pages/subissue.aspx?cliid=3746&parentid=13&preview=
False.
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First, the ACA requires health insurers to comply with a set of federal standards (“market
reforms”) to ensure that individuals may purchase, keep, and renew coverage that provides a
minimum level of benefits and consumer protections, with some limits on costs. Second, the law
establishes competitive private health insurance exchanges (also known as marketplaces) through
which individuals and small employers are able to compare and enroll in qualified health plans.
Exchanges operate in every state and the District of Columbia. They are administered by states or
by the federal government, or through a partnership between the state and federal governments.
Qualified individuals who enroll in exchange plans may receive financial assistance if they meet
income and certain other requirements. Refundable tax credits are available to individuals and
families with incomes between 100% and 400% of the federal poverty level (FPL) to help pay the
insurance premium. The premium tax credits are available upon enrollment so that eligible
individuals and families can choose to receive the subsidy immediately rather than wait until they
file taxes the following year. In addition, certain individuals and families receiving the tax credit
may be eligible for cost-sharing subsidies to reduce their out-of-pocket costs (e.g., deductibles,
copays) when receiving health services. Small employers with fewer than 25 full-time equivalent
employees (FTEs) may also use the exchanges to purchase insurance coverage for their
employees and may qualify for a tax credit to help cover the cost of providing that coverage.
In June 2015, the U.S. Supreme Court in King v. Burwell ruled that the premium tax credits are
available to all qualified individuals who enroll in exchange plans and meet the necessary income
and other requirements, regardless of whether the exchange is administered by the state or the
federal government.3
Third, the ACA’s “individual mandate” requires most U.S. citizens and legal residents to obtain
coverage. Those who remain uninsured may have to pay a penalty unless they qualify for an
exemption. The individual mandate is intended to encourage healthy individuals to participate in
the insurance market and not wait until they get sick to buy coverage. Finally, the law requires
larger employers with 50 or more FTEs to offer health coverage that meets affordability and
adequacy standards for their full-time employees and those workers’ dependents. Employers who
do not comply with these requirements may be subject to a tax if one or more of their employees
purchase coverage through an exchange and receive a subsidy. The purpose of the ACA’s
employer requirements is to encourage larger firms to maintain affordable and adequate coverage
for their employees.
The ACA coupled its private insurance provisions with the requirement that states expand their
Medicaid programs to cover all nonelderly individuals with incomes up to 138% FPL. Those with
higher incomes, up to 400% FPL, may be eligible to get subsidized coverage through an
exchange. In June 2012, the U.S. Supreme Court in NFIB v. Sebelius found the Medicaid
expansion to be unconstitutionally coercive and prohibited the federal government from enforcing
it.4 The Court’s decision made Medicaid expansion optional for states.
In addition to expanding access to insurance coverage, the ACA contains hundreds of other
provisions that address health care access, costs, and quality. They include new programs to test

3 King v. Burwell, No. 14-114 slip op. (June 25, 2015), http://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf.
4 NFIB v. Sebelius, No. 11-393, slip op. (June 28, 2012), http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf.
For more information, see CRS Report R42367, Medicaid and Federal Grant Conditions After NFIB v. Sebelius:
Constitutional Issues and Analysis
, by Kenneth R. Thomas.
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alternative ways of delivering and paying for health care. The law also includes new taxes and
fees as well as adjustments to Medicare payments to hospitals and other health care providers.
These provisions are designed to offset the federal spending on exchange subsidies and Medicaid
expansion.
ACA’s Impact on Federal Spending
Implementation of the ACA is affecting both mandatory and discretionary spending. Mandatory
spending
—also referred to as direct spending—is controlled through authorizing laws.5 It
includes spending on entitlement programs such as Medicare and Social Security. Authorizing
laws may provide permanent or temporary appropriations or other forms of budget authority for
such spending. When the authorizing law contains no appropriations, mandatory programs may
be funded through the annual appropriations process. This is sometimes referred to as
“appropriated mandatory” or “appropriated entitlement” spending.6 Discretionary spending is
both controlled and funded through the annual appropriations process. It typically covers the
routine costs of running federal agencies and offices, including wages and salaries.7
Federal spending on ACA implementation can be grouped into three categories: (1) mandatory
spending on expanding insurance coverage, (2) mandatory spending on other programs, and (3)
discretionary spending. Each of these categories is briefly discussed below.
Mandatory Spending on Expanding Insurance Coverage
This category accounts for most of the federal spending under the ACA. It includes the exchange
subsidies (i.e., premium tax credits and cost-sharing subsidies), the federal government’s share of
the costs of Medicaid expansion, and tax credits for small employers. The Congressional Budget
Office (CBO) and the Joint Committee on Taxation (JCT) projected that this and other ACA
mandatory spending (discussed in the second category, below) would be more than offset by (1)
revenues from the ACA’s new taxes and fees, and (2) savings from the law’s adjustments to
Medicare provider payments that are projected to slow the rate of growth of Medicare spending.8
Mandatory Spending on Other Programs
The ACA authorized new Medicare and Medicaid spending. For example, it phased out the
Medicare prescription drug benefit “donut hole” through a combination of subsidies and
manufacturer discounts, and it increased Medicare payments for primary care services and

5 Authorizing legislation generally refers to substantive legislation, reported by a committee (or committees) of
jurisdiction other than the House or Senate Appropriations Committees, that establishes or continues the operation of a
federal program or agency either indefinitely or for a specific period.
6 For further information on direct spending, see CRS Report RS20129, Entitlements and Appropriated Entitlements in
the Federal Budget Process
, by Bill Heniff Jr.
7 For further information on discretionary spending, see CRS Report R42388, The Congressional Appropriations
Process: An Introduction
, by Jessica Tollestrup.
8 U.S. Congressional Budget Office, letter to the Honorable Nancy Pelosi, Speaker, U.S. House of Representatives,
providing an estimate of the direct spending and revenue effects of ACA, as amended by HCERA (March 20, 2010),
http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf.
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medical education. The ACA also included numerous appropriations that are providing billions of
dollars of mandatory funding to support grant programs and other activities authorized by the
law.9 For example, the law funded temporary insurance programs for targeted groups prior to the
exchanges becoming operational, and it provided funding for grants to states to plan and establish
health insurance exchanges. The ACA included a permanent appropriation, available for 10-year
periods, for the Center for Medicare & Medicaid Innovation (CMMI), within the Centers for
Medicare & Medicaid Services (CMS), to test and implement innovative health care payment and
service delivery models.
In addition, the ACA created four special funds and appropriated amounts to each one. First, the
Community Health Center Fund (CHCF) has provided almost $11 billion over five years
(FY2011-FY2015) for the federal health centers program and the National Health Service
Corps.10 Second, the Patient-Centered Outcomes Research Trust Fund (PCORTF) is supporting
patient-centered comparative clinical effectiveness research through FY2019 with a mix of
appropriations, fees on health plans, and transfers from the Medicare trust funds. Third, the
Prevention and Public Health Fund (PPHF), for which the ACA provided a permanent annual
appropriation, is supporting prevention, wellness, and other public health-related programs and
activities. Finally, the Health Insurance Reform Implementation Fund (HIRIF), for which the
ACA appropriated $1 billion, helped pay for the initial administrative costs of implementing the
law.
Discretionary Spending
The ACA is affecting discretionary spending in two ways. First, the law created numerous new
discretionary grant programs and provided each of them with an authorization of appropriations.
To date, however, few of these programs have received discretionary funding through annual
appropriations acts, though several of them have been supported with mandatory funds from the
PPHF.11 Second, the two agencies primarily responsible for implementing the ACA’s provisions
to expand insurance coverage—CMS’s Center for Consumer Information and Insurance
Oversight (CCIIO) and the Internal Revenue Service (IRS)—are incurring significant costs in
connection with administering and enforcing the law. Both agencies requested increases in
funding in each of their past four budget submissions (i.e., FY2013-FY2016) to help pay for ACA
implementation. But congressional appropriators have not provided either agency with any

9 For a summary of all the ACA’s mandatory appropriations, and the status of obligation of those funds, see CRS
Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by C. Stephen Redhead.
10 The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10, 129 Stat. 87) extended CHCF
funding for the health centers program and the NHSC for two years by appropriating a total of $3.910 billion to the
fund for each of FY2016 and FY2017. Of that amount, $3.6 billion is for the health centers program and the remaining
$310 million is for the NHSC.
11 The ACA also reauthorized funding for many existing discretionary grant programs authorized under the Public
Health Service Act; notably, the federal health workforce programs administered by the Health Resources and Services
Administration (HRSA). The authorizations of appropriations for many of these programs expired prior to the ACA’s
enactment, though most of them were still receiving annual appropriations. The ACA also permanently reauthorized
appropriations for the federal health centers program and for programs and services provided by the Indian Health
Service (IHS). Congressional appropriators have in general continued to provide discretionary funding for these long-
standing programs, though typically at funding levels below the amounts authorized by the ACA. For more details on
all the authorizations (and reauthorizations) of discretionary funding in ACA, including the FY2011-FY2015 funding
levels for programs that received an appropriation, see CRS Report R41390, Discretionary Spending Under the
Affordable Care Act (ACA)
, coordinated by C. Stephen Redhead.
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additional discretionary funds. CMS instead has relied on discretionary fund transfers from other
accounts, amounts from the Nonrecurring Expenses Fund (NEF),12 and ACA mandatory funds
(i.e., HIRIF, PPHF) to support its ACA implementation activities. CMS also has transferred
HIRIF funds to the IRS.
ACA Provisions in Authorization Legislation
Table 1 summarizes the authorizing legislation to amend the ACA that has been enacted since the
ACA became law in March 2010. Each table entry includes the public law number and date of
enactment, the original bill number and sponsor, and a brief description and explanation of the
change(s) made to the ACA. The laws are listed in reverse chronological order, beginning with
the most recently enacted legislation and extending back to the first measure signed into law
following enactment of the ACA and the accompanying package of amendments in the Health
Care and Education Reconciliation Act (HCERA).13
During the 111th Congress, when the House was still under Democratic control, a number of
clarifications and technical adjustments to the law were enacted. In the 112th and 113th
Congresses, several more substantive ACA amendments that garnered bipartisan support were
signed into law. For example, Congress repealed Title VIII of the ACA—the Community Living
Assistance Services and Supports (CLASS) Act—which would have established a voluntary,
long-term care insurance program to pay for community-based services and supports for
individuals with functional limitations. Lawmakers also repealed a tax-filing provision (IRS Form
1099) that had been included in the ACA, and they reduced the PPHF annual appropriation over
the period FY2013-FY2021 by a total of $6.25 billion.
In compiling Table 1, CRS made decisions about which laws—or specific provisions in a
particular law—to include, and which ones to leave out. CRS elected to include only those
provisions that made changes (including funding extensions or rescissions) to new programs and
activities first authorized and funded by the ACA. CRS excluded provisions addressing
established programs and activities that predate the ACA and were amended or extended by it.
For example, the ACA extended multiple existing Medicare and Medicaid program payments and
activities that have since been further extended and/or modified by provisions in more recently
enacted laws. The ACA also extended funding for a number of existing grant programs whose
funding has been further extended by provisions in newer laws. None of these types of provisions
are included in Table 1.
Table 2 summarizes the ACA provisions in authorizing legislation that passed the House in the
112th and 113th Congresses (2011-2014) but saw little if any further legislative action. Two of
these bills, both of which passed the House in the 113th Congress, were taken up and approved by
the Democratic-led Senate, though neither measure became law. Table 2 also summarizes the
ACA legislation that has passed the House to date in the 114th Congress.

12 The Nonrecurring Expenses Fund is an account within the Department of the Treasury. The HHS Secretary is
authorized to transfer to the NEF unobligated balances of expired discretionary funds. NEF funds are available until
expended for use by the HHS Secretary for capital acquisitions including facility and information technology
infrastructure.
13 See footnote 1.
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The House-passed legislation includes stand-alone bills as well as provisions in broader, often
unrelated measures that would (1) repeal the ACA in its entirety and, in some cases, replace it
with new law; (2) repeal, or by amendment restrict or otherwise limit, specific provisions in the
ACA; (3) eliminate appropriations provided by the ACA and rescind all unobligated funds;14 (4)
replace the mandatory appropriations for one or more ACA programs with authorizations of
(discretionary) appropriations, and rescind all unobligated funds; and (5) block or otherwise delay
implementation of specific ACA provisions.
Generally, Table 2 lists only legislation that, if enacted, would have a direct impact on the ACA
and its implementation; measures that would not have such an effect are not included. Thus,
budget resolutions, which are only binding on certain matters before Congress, are not included.15
On July 30, 2014, the House approved a simple resolution (H.Res. 676) that authorized Speaker
John Boehner to sue the Obama Administration on behalf of the House of Representatives over
implementation of the ACA’s private health insurance provisions. The House filed a lawsuit in
federal district court on November 21, 2014, seeking to invalidate two actions taken by the
Administration. First, the lawsuit claims that HHS abused its authority by delaying enforcement
of the ACA’s employer mandate. Second, it argues that Congress has never appropriated funds for
the ACA’s cost-sharing subsidies.16




14 Appropriations bills provide agencies with budget authority, which is the legal authority to incur financial obligations
(e.g., hire employees, purchase services, award grants, or sign contracts) that result in immediate or future government
expenditures (or outlays). Budget authority is generally made available for obligation during a specified time period,
typically the upcoming fiscal year. Once budget authority reaches the end of that time period, it “expires,” meaning that
it is no longer available for obligation. A rescission is a provision of law that cancels budget authority prior to when it
would otherwise expire, making it unavailable for future obligation. For further explanations of these terms, see GAO,
A Glossary of Terms Used in the Federal Budget Process, GAO-05-734SP, September 2005, pp. 85-86, available at
http://www.gao.gov.
15 The House has taken multiple votes on amendments to, and passage of, budget resolutions that expressed support for
a full repeal of the ACA, or the repeal or amendment of specific provisions in the law. However, budget resolutions are
concurrent resolutions that apply only to Congress. They are not presented to the President for his signature and do not
have the force of law. The House approved budget resolutions for FY2012 and FY2013 (H.Con.Res. 34 and
H.Con.Res. 112, respectively) during the 112th Congress and passed budget resolutions for FY2014 and FY2015
(H.Con.Res. 25 and H.Con.Res. 96, respectively) during the 113th Congress. Each of those four House budget
resolutions included language addressing full repeal of the ACA. This year the House and the Senate each passed an
FY2016 budget resolution (H.Con.Res. 27 and S.Con.Res. 11, respectively). Both measures—as well as the subsequent
conference agreement (S.Con.Res. 11) approved by the two chambers—included language calling for full repeal of the
ACA.
16 United States House of Representatives v. Burwell, 1:14-cv-01967 (D.D.C. 2014), http://www.speaker.gov/sites/
speaker.house.gov/files/HouseLitigation.pdf.
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Table 1. Enacted Legislation That Modified, or Extended or Rescinded Funding for, Programs Established by the ACA

Public Law
and Date of

Enactment
Bill (Sponsor)
Summary of ACA Provisions
114th Congress
P.L. 114-10
H.R. 2 (Burgess)
Medicare Access and CHIP Reauthorization Act of 2015. Among its many provisions, P.L. 114-10:
Apr. 16, 2015

Amended Section 1848(p) of the Social Security Act (SSA), as added by ACA Section 3007, to terminate application of the
physician value-based payment modifier (VBM) at the end of 2018. [Beginning in 2019, the VBM wil be used as one of the
components of the composite score under the new Merit-Based Incentive Payment System (MIPS).]

Appropriated a total of $3.910 billion to the CHCF for each of FY2016 and FY2017; $3.600 billion for the health centers
program, and $310 million for the NHSC.

Appropriated $60 million for each of FY2016 and FY2017 for graduate medical education (GME) payments to teaching health
centers, authorized by ACA Section 5508(c).

Appropriated $400 million for each of FY2015 through FY2017 for the Maternal, Infant, and Early Childhood Home Visiting
program, established by ACA Section 2951.

Appropriated $75 million for each of FY2016 and FY2017 for the Personal Responsibility Education Program (PREP),
established by ACA Section 2953.

Appropriated $85 million for each of FY2016 and FY2017 for the Health Profession Opportunity Grant (HPOG) program,
established by ACA Section 5507(a).

Appropriated $20 million for the two-year period FY2016 through FY2017 to develop Medicaid adult quality measures,
pursuant to ACA Section 2701.
113th Congress
P.L. 113-93
H.R. 4302 (Pitts)
Protecting Access to Medicare Act of 2014. Among its many provisions, P.L. 113-93:
Apr. 1, 2014

Eliminated paragraph (2) of ACA Section 1302(c), which capped deductibles for small group health plans at $2,000 for singles
and $4,000 for families (indexed after 2014 to average per capita premium costs). [Insurers were finding it difficult staying
within the deductible cap while covering all essential health benefits and meeting the 60% actuarial value (AV) level for
bronze plans. In fact, CMS had already agreed to waive the deductible cap if a plan could not “reasonably reach” the AV level
without exceeding the cap.]

Appropriated $400 million for the first half of FY2015 for the Maternal, Infant, and Early Childhood Home Visiting program,
established by ACA Section 2951. [Superseded by the appropriation in P.L. 114-10.]

Appropriated $85 million for FY2015 for HPOG program, established by ACA Section 5507(a).

Appropriated $75 million for FY2015 for the PREP, established by ACA Section 2953.
CRS-7


Public Law
and Date of
Enactment

Bill (Sponsor)
Summary of ACA Provisions
112th Congress
P.L. 112-240
H.R. 8 (Camp)
American Taxpayer Relief Act of 2012. Among its many provisions, P.L. 112-240:
Jan. 2, 2013

Transferred 10% of the remaining unobligated Consumer Operated and Oriented Plan (CO-OP) program funds to a new
CO-OP contingency fund (to provide assistance and oversight to CO-OP loan recipients) and rescinded the other 90% of
these funds.a

Repealed ACA Title VIII, the Community Living Assistance Services and Supports (CLASS) Act.

Repealed the ACA’s appropriations for the National Clearinghouse for Long-Term Care Information and rescinded al
unobligated funds.
P.L. 112-141
H.R. 4348 (Mica)
Moving Ahead for Progress in the 21st Century Act, or “MAP-21.” Among its many provisions, P.L. 112-141 further
July 6, 2012
modified the Medicaid disaster-recovery FMAP adjustment (see entry for P.L. 112-96, below) by changing the adjustment factor
and the effective date.
P.L. 112-96
H.R. 3630 (Camp)
Middle Class Tax Relief and Job Creation Act of 2012. Among its many provisions, P.L. 112-96:
Feb. 22, 2012

Amended ACA Section 4002 to reduce the PPHF annual appropriations over the period FY2013-FY2021 by a total of $6.25
billion to help offset the cost of extending the payroll tax cut and other programs in P.L. 112-96.

Amended SSA Section 1923(f) to extend by one year the disproportionate share hospital (DSH) allotment reduction
imposed by ACA Section 3203.

Amended SSA Section 1905(aa), as added by ACA Section 2006, to make a technical correction to the formula to phase
down the Medicaid disaster-recovery Federal Medical Assistance Percentage (FMAP) adjustment as originally intended. [The
purpose of the adjustment was to help Louisiana avoid a significant reduction in its federal Medicaid match (i.e., FMAP) in the
aftermath of Hurricane Katrina. As written in ACA Section 2006, the formula for the disaster-recovery FMAP adjustment
unintentionally caused the FMAP adjustment to increase, rather than phase down, each year the state qualifies for the
adjustment.]
P.L. 112-56
H.R. 674 (Herger)
3% Withholding Repeal and Job Creation Act. Among its many provisions, P.L. 112-56 amended IRC Section 36B, as added
Nov. 21, 2011
by ACA Section 1401(a) (as amended), by modifying the calculation of Modified Adjusted Gross Income (MAGI) to include Social
Security benefits. MAGI will be used to determine eligibility for exchange subsidies and Medicaid, beginning in 2014.
P.L. 112-9
H.R. 4 (Lungren)
Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011.
Apr. 14, 2011
Amended IRC Section 6041, as amended by ACA Section 9006, to repeal the requirement that businesses file an information
report (IRS Form 1099) whenever they pay a vendor more than $600 for goods in a single year. To pay for the 1099 repeal, P.L.
112-9 amended Section 36B of the Internal Revenue Code (IRC), as added by ACA Section 1401(a), by further modifying the
sliding scale that determines the amount of excess premium tax credits that individuals have to repay based on household income
(see entry for P.L. 111-309, below).
CRS-8


Public Law
and Date of
Enactment

Bill (Sponsor)
Summary of ACA Provisions
111th Congress
P.L. 111-383
H.R. 6523 (Skelton)
Ike Skelton National Defense Authorization Act for Fiscal Year 2011. Extended TRICARE coverage to dependent adult
Jan. 7, 2011
children up to age 26, to conform to the private health insurance requirements under the ACA.
P.L. 111-312
H.R. 4853 (Oberstar)
Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010. Amended ACA Section 10909
Dec. 17, 2010
to extend the nonrefundable adoption tax credit through tax year 2012. The adoption tax credit helps offset the cost of qualified
adoption expenses. [Subsequently, P.L. 112-240 made the nonrefundable adoption tax credit permanent.]
P.L. 111-309
H.R. 4994 (Lewis)
Medicare and Medicaid Extenders Act of 2010. To help offset the costs of the Medicare and Medicaid program extensions
Dec. 15, 2010
and the postponement of cuts in Medicare physician payments, P.L. 111-309 amended IRC Section 36B, as added by ACA Section
1401(a), to modify the amount of excess premium tax credits that individuals would have to repay. The ACA created a sliding
scale for such repayments based on household income. P.L. 111-309 modified the sliding scale. [Under the ACA, the amount
received in premium credits is based on income as reported on tax returns. These amounts are reconciled the following year,
which could result in an overpayment of credits if income increases. The ACA placed limits on the amount of any premium credit
overpayment that had to be repaid to the government.]
P.L. 111-226
H.R. 1586 (Rangel)
FAA Air Transportation Modernization and Safety Improvement Act. Among its many provisions, P.L. 111-226
Aug. 10, 2010
amended SSA Section 1927(k)(1)(B)(i)(IV) (as added by ACA Section 2503(a)(2)(B), as amended by HCERA Section 1101(c)) by
modifying the definition of average manufacturer price (AMP) to include inhalation, infusion, implanted, or injectable drugs that
are not general y dispensed through a retail community pharmacy.
P.L. 111-173
H.R. 5014 (Filner)
[No title.] Amended IRC Section 5000A(f)(1)(A), as added by ACA Section 5101(b), to clarify that health care provided by the
May 27, 2010
Department of Veterans Affairs constitutes minimal essential health care coverage as required by the ACA. [Beginning in 2014,
the ACA requires most U.S. citizens and legal residents to have minimal essential health care coverage or pay a penalty.]
P.L. 111-159
H.R. 4887 (Skelton)
TRICARE Affirmation Act. Amended IRC Section 5000A(f)(1)(A), as added by ACA Section 5101(b), to clarify that health
Apr. 26, 2010
care provided under TRICARE, TRICARE for Life, and the Nonappropriated Fund Health Benefits program constitutes minimal
essential health care coverage as required by the ACA. [Beginning in 2014, the ACA requires most U.S. citizens and legal
residents to have minimal essential health care coverage or pay a penalty.]
Source: Prepared by the Congressional Research Service based on the text of the public laws listed in the table.
a. The FY2011 and FY2012 Labor-HHS-ED appropriations acts (P.L. 112-10 and P.L. 112-74, respectively) rescinded a total of $2.6 billion of the ACA’s original $6
billion appropriation for the CO-OP program. At the time P.L. 112-240 was enacted, according to HHS budget documents, the CO-OP program had an unobligated
balance of $2.532 billion. P.L. 112-240 rescinded 90% of that amount (i.e., $2.279 billion), and transferred the remaining funds (i.e., $253 million) to the contingency
fund. In all, Congress has rescinded $4.879 billion of the $6 billion CO-OP program appropriation.




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Table 2. ACA Provisions in Bills Approved by the House in the 112th, 113th, and 114th Congresses

Bill (Sponsor)
Bill Title, House Vote, Summary of ACA Provisions
114th Congress
H.R. 1190 (Roe)
Protecting Seniors’ Access to Medicare Act of 2015. Passed the House by a vote of 244-154 on June 23, 2015. H.R. 1190 would repeal
the authority and appropriations for the Independent Payment Advisory Board (IPAB). It also would reduce the Prevention and Public Health
Fund (PPHF) annual appropriations over the period FY2017-FY2025 by a total of $8.846 billion to offset the cost of repealing IPAB. [Note: This
is the second time the House has passed a stand-alone bill to repeal IPAB.]
H.R. 160 (Paulsen)
Protect Medical Innovation Act of 2015. Passed the House by a vote of 280-140 on June 18, 2015. H.R. 160 would repeal the ACA’s 2.3%
excise tax on medical devices. [Note: This is the second time the House has passed a stand-alone bill to repeal the medical device tax.]
H.R. 1191 (Barletta)
Protecting Volunteer Firefighters and Emergency Responders Act. Passed the House by a vote of 415-0 on March 17, 2015. H.R. 1191
would exclude the hours worked by volunteer firefighters and emergency medical responders from being counted toward the ACA’s 30-hour-a-
week benchmark that determines whether an employee is classified as ful -time. [Note: The ACA requires employers with at least 50 FTEs to
offer affordable health coverage or risk paying a penalty if at least one ful -time worker gets a premium tax credit for coverage purchased at an
exchange. Last year the IRS ruled that it will not require volunteer emergency responders to count towards these ACA requirements. H.R.
1191 would codify that ruling.] The House passed the same legislation in January 2015 (see H.R. 33 below) and in March 2014 (see H.R. 3979 in
the 113th Congress). The Senate took up H.R. 1191 and used it as the legislative vehicle for the Iran Nuclear Agreement Review Act of 2015, which the
Senate passed by a vote of 98-1 on May 7, 2015.

H.R. 596 (Byrne)
A bill to repeal the Patient Protection and Affordable Care Act. Passed the House by a vote of 239-186 on February 3, 2015. H.R. 596
would repeal the ACA in its entirety and restore the provisions of law amended or repealed by the ACA as if it had not been enacted. It also
instructs four House Committees (Education & Workforce, Energy & Commerce, Judiciary, and Ways & Means) each to report health reform
legislation that addresses various issues specified in the bill. [Note: This is the fourth time the House has passed a full-repeal bill.]
H.R. 33 (Barletta)
Protecting Volunteer Firefighters and Emergency Responders Act. Passed the House by a vote of 401-0 on January 12, 2015. H.R. 33
would exclude the hours worked by volunteer firefighters and emergency medical responders from being counted toward the ACA’s 30-hour-a-
week benchmark that determines whether an employee is classified as ful -time. [Note: The ACA requires employers with at least 50 FTEs to
offer affordable health coverage or risk paying a penalty if at least one ful -time worker gets a premium tax credit for coverage purchased at an
exchange. Last year the IRS has ruled that it will not require volunteer emergency responders to count towards these ACA requirements. H.R.
33 would codify that ruling.] The House passed the same measure in March 2014 (see H.R. 3979 in the 113th Congress). The Senate took up H.R.
33 and substituted language to amend the Continuing Appropriations Resolution, 2015. As amended by the Senate, H.R. 33 passed both chambers and was
signed into law (P.L. 114-3).

H.R. 30 (Young, T.)
Save American Workers Act of 2014. Passed the House by a vote of 252-172 on January 8, 2015. H.R. 30 would amend the ACA’s
definition of ful -time employees to those who work on average at least 40 hours a week. [Note: The ACA requires employers with at least 50
full-time equivalent employees (FTEs) to offer affordable health coverage or risk paying a penalty if at least one full-time worker gets a premium
tax credit for coverage purchased at an exchange. Ful -time employees are defined as those who work on average at least 30 hours a week. The
House passed the same measure in 2014; see H.R. 2575 below.]
H.R. 22 (Davis, R.)
Hire More Heroes Act of 2014. Passed the House by a vote of 412-0 on January 6, 2015. H.R. 22 would exclude employees who receive
health care through the Department of Veterans Affairs or TRICARE from an employer’s FTE count. [Note: The House passed a similar
measure in 2014; see H.R. 3474 below.]
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Bill (Sponsor)
Bill Title, House Vote, Summary of ACA Provisions
113th Congress
H.R. 3522 (Cassidy)
Employer Health Care Protection Act of 2014. Passed the House by a vote of 247-167 on September 11, 2014. H.R. 3522 would have
permitted health insurance companies to continue to offer group coverage that was in effect on any date during 2013, even if the coverage does
not meet the ACA’s essential health benefit standards and other market reforms that took effect at the beginning of 2014. Insurers could offer
such coverage to existing or new enrol ees through December 31, 2018, but could not offer the coverage through health insurance exchanges.
[Note: The House passed a comparable measure in 2013; see H.R. 3350 below.]
H.R. 4414 (Carney)
Expatriate Health Coverage Clarification Act of 2014. Passed the House by a vote of 268-150 on April 29, 2014. H.R. 4414 would have
exempted from certain ACA requirements expatriate health care plans offered to individuals working outside the United States. These plans are
often used by corporate executives, nongovernmental organization employees, foreign aid workers, contractors, and others working abroad.
U.S. insurance companies offering these plans are required to comply with the ACA whereas foreign insurance companies are not. [Note: A
modified version of this legislation was enacted into law as Division M of the Consolidated and Further Continuing Appropriations Act, 2015
(P.L. 113-235).]
H.R. 4194 (Issa)
Government Reports Elimination Act of 2014. Passed the House by voice vote on April 28, 2014. Among its provisions, H.R. 4194 would
have modified the ACA’s requirement for periodic reviews and evaluations of all federal disease prevention and health promotion programs.
Instead of joint reviews conducted by the HHS and GAO, the reviews would be conducted by HHS alone. H.R. 4194 subsequently passed the
Senate, amended, by unanimous consent on September 16, 2014.

H.R. 2575 (Young, T.)
Save American Workers Act of 2014. Passed the House by a vote of 248-179 on April 3, 2014. H.R. 2575 would have amended the ACA’s
definition of ful -time employees to those who work on average at least 40 hours a week. [Note: The ACA requires employers with at least 50
full-time equivalent employees (FTEs) to offer affordable health coverage or risk paying a penalty if at least one full-time worker gets a premium
tax credit for coverage purchased at an exchange. Ful -time employees are defined as those who work on average at least 30 hours a week.]
H.R. 4015 (Burgess)
SGR Repeal and Medicare Provider Payment Modernization Act of 2014. Passed the House by a vote of 238-181 on March 14, 2014.
H.R. 4015 would have replaced the Sustainable Growth Rate (SGR) formula, which determines the annual updates to Medicare’s payment rates
for physician services, with new systems for establishing those payment rates. To help pay for its cost, H.R. 4015 would have delayed
enforcement of the ACA’s individual mandate by five years by shifting the schedule of penalties for individuals who do not comply with the
mandate (or obtain an exemption) to begin in 2019. CBO estimated that this would result in 13 million fewer Americans with health insurance
coverage in 2018 relative to current-law projections.
H.R. 3979 (Barletta)
Protecting Volunteer Firefighters and Emergency Responders Act of 2014. Passed the House by a vote of 410-0 on March 11, 2014.
H.R. 3979 would have excluded the hours worked by volunteer firefighters and emergency medical responders from being counted towards the
ACA’s 30-hour-a-week benchmark that determines whether an employee is classified as ful -time. [Note: The ACA requires employers with at
least 50 FTEs to offer affordable health coverage or risk paying a penalty if at least one full-time worker gets a premium tax credit for coverage
purchased at an exchange. Prior to passage of H.R. 3979, the IRS ruled that it will not require volunteer emergency responders to count
towards these ACA requirements. H.R. 3979 would have codified that ruling.] The Senate passed H.R. 3979 by a vote of 59-38 on April 7, 2014,
after adding a five-month extension of unemployment benefits to the bill, among other provisions, and renaming it the Emergency Unemployment
Compensation Act of 2014. No further action was taken on that measure. H.R. 3979 subsequently was used as the legislative vehicle for the FY2015
National Defense Authorization Act (P.L. 113-291).

H.R. 3474 (Davis, R.)
Hire More Heroes Act of 2014. Passed the House by a vote of 406-1 on March 11, 2014. H.R. 3474 would have permitted an employer to
exclude employees who receive health care through the Department of Veterans Affairs or TRICARE from its FTE count.
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Bill (Sponsor)
Bill Title, House Vote, Summary of ACA Provisions
H.R. 1814 (Schock)
Equitable Access to Care and Health (EACH) Act. Passed the House by voice vote on March 11, 2014. H.R. 1814 would have expanded
the religious exemption in the ACA by exempting from the law’s insurance mandate any individual who objects to purchasing health coverage
because of sincerely held religious beliefs. [Note: The ACA’s religious exemption applies only to religious sects that are recognized by the Social
Security Administration as being conscientiously opposed to accepting insurance benefits (e.g., Amish).]
H.R. 4118 (Jenkins)
Suspending the Individual Mandate Penalty Law Equals (SIMPLE) Fairness Act. Passed the House by a vote of 250-160 on March 5,
2014. H.R. 4118 would have delayed enforcement of the ACA’s individual mandate by one year by shifting the schedule of penalties for
individuals who do not comply with the mandate (or obtain an exemption) to begin in 2015. [Note: The House passed similar legislation in 2013;
see H.R. 2668 below.]
H.R. 7 (Smith)
No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2014. Passed the House by a vote of 227-188 on
January 28, 2014. H.R. 7 would have prohibited exchange applicants from obtaining premium tax credits or cost-sharing subsidies to help
purchase health plans that cover elective abortions, and would have prohibited tax credits for health plans offered by an employer that include
elective abortion coverage. Individuals would still be able to purchase separate abortion coverage, but would not be able to receive a tax credit
or cost-sharing subsidy. H.R. 7 also would have prohibited OPM-contracted multi-state plans from including elective abortion coverage. [Note:
The ACA permits exchange applicants to obtain premium tax credits and cost-sharing subsidies to help purchase health plans that cover elective
abortions; however, the law prohibits the use of those federal funds to pay for abortion services and requires plans to collect an abortion
surcharge from enrollees to pay for such services. The ACA also specifies that at least one multi-state plan offered in an exchange must not
include elective abortion coverage.]
H.R. 3362 (Lee)
Exchange Information Disclosure Act. Passed the House by a vote of 259-154 on January 16, 2014. H.R. 3362 would have required the
HHS Secretary to submit to Congress and make public a detailed weekly report, through March 2015, on (1) consumer interactions with
healthcare.gov (or subsequent sites) and efforts undertaken to remedy problems that impact consumers; and (2) cal s to the federal consumer
service call center, including the number of calls received by the call center, problems identified by users, and referrals of those calls. The
Secretary also would have been required to make public a list (with contact information) of all navigators and certified application counselors
trained and certified by exchanges, and a list of all agents and brokers trained and certified by the federally facilitated exchange. Both lists would
have to be updated weekly through March 2015.
H.R. 3811 (Pitts)
Health Exchange Security and Transparency Act of 2014. Passed the House by a vote of 291-122 on January 10, 2014. H.R. 3811 would
have required the HHS Secretary to notify affected individuals within two business days of a breach of their personally identifiable information
maintained by an exchange.
H.R. 3350 (Upton)
Keep Your Health Plan Act of 2013. Passed the House by a vote of 261-157 on November 15, 2013. H.R. 3350 would have permitted
health insurance companies to continue to offer individual coverage that was in effect as of January 1, 2013, even if the coverage did not meet
the ACA’s essential health benefit standards and other market reforms that took effect at the beginning of 2014. Insurers could offer such
coverage to existing or new enrol ees at any time during 2014, but could not offer the coverage through health insurance exchanges. [Note:
This legislation was prompted by the decision of insurers to send cancel ation notices to individuals and smal businesses with health plans in the
individual and small group markets. The Administration also has taken steps to address this issue. On November 14, 2013, it announced a
transitional policy under which insurers may choose, subject to the approval of state insurance regulators, to renew noncompliant health plans
that have been cancelled, or are slated for cancellation. Under the ACA, insurers are not permitted to sell noncompliant coverage to new
enrollees. H.R. 3350 would allow insurers to sell such coverage in the individual market during 2014.]
H.R. 2775 (Black)
No Subsidies Without Verification Act. Passed the House by a vote of 235-191 on September 12, 2013. H.R. 2775 would have required
the HHS Inspector General to certify to Congress that a program was in place to verify the household income of exchange applicants before
making any premium tax credits or cost-sharing subsidies available. [Note: H.R. 2775 became the legislative vehicle for the FY2014 Continuing
Appropriations Act, P.L. 113-46. That act incorporated a modified version of the language in H.R. 2775.]
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Bill (Sponsor)
Bill Title, House Vote, Summary of ACA Provisions
H.R. 2009 (Price)
Keep the IRS Off Your Health Care Act of 2013. Passed the House by a vote of 232-185 on August 2, 2013. H.R. 2009 would have
prohibited the Internal Revenue Service (IRS) from implementing or enforcing any provisions of the ACA.
H.R. 2668 (Young)
Fairness for American Families Act. Passed the House by a vote of 251-174 on July 17, 2013. H.R. 2668 would have delayed enforcement
of the ACA’s individual mandate by one year by shifting the schedule of penalties for individuals who do not comply with the mandate (or obtain
an exemption) to begin in 2015. It also would have incorporated the provisions in H.R. 2667 (see below) to delay the employer mandate and
related reporting requirements.
H.R. 2667 (Griffin)
Authority for Mandate Delay Act. Passed the House by a vote of 264-161 on July 17, 2013. H.R. 2667 would have delayed for one year
certain ACA reporting requirements for insurers and employers as wel as the penalties for employers who do not offer affordable coverage.
[Note: H.R. 2667 would have essential y codified the Administration’s announcement on July 2, 2013, that it was delaying the ACA employer
mandate and related reporting requirements.]
H.R. 45 (Bachmann)
A bill to repeal the Patient Protection and Affordable Care Act. Passed the House by a vote of 229-195 on May 16, 2013. H.R. 45
would have repealed the ACA in its entirety and restored the provisions of law amended or repealed by the ACA as if it had not been enacted.
112th Congress
H.R. 6684 (Cantor)
Spending Reduction Act of 2012. Passed the House by a vote of 215-209 on December 20, 2012. H.R. 6684 would have eliminated the
FY2013 sequestration of direct defense spending (as required under the Budget Control Act of 2011), reduced the FY2013 overal discretionary
cap by $19 billion, and implemented numerous other mandatory spending reductions. Among its provisions, H.R. 6684 would have (1) repealed
the authority and appropriations for the exchange planning and establishment grants and rescinded al unobligated funds; (2) repealed the
authority and appropriations for the PPHF and rescinded all unobligated funds; (3) rescinded all remaining unobligated funds for the Consumer
Operated and Oriented Plan (CO-OP) program; and (4) eliminated al limits on repayment of any premium credit overpayment, making
individuals liable for the full amount.
H.R. 6079 (Cantor)
Repeal of Obamacare Act. Passed the House by a vote of 244-185 on July 11, 2012. H.R. 6079 would have repealed the ACA in its entirety
and restored the provisions of law amended or repealed by the ACA as if it had not been enacted.
H.R. 436 (Paulsen)
Health Care Cost Reduction Act of 2012. Passed the House by a vote of 270-146 on June 7, 2012. H.R. 436 would have (1) repealed the
ACA’s 2.3% excise tax on medical devices; (2) repealed the law’s restrictions on using tax-preferred accounts to pay for over-the-counter drugs;
(3) allowed individuals to recoup up to $500 of unused funds remaining in their flexible spending account (FSA) after the end of the plan year;
and (4) eliminated all limits on repayment of any premium credit overpayment, making individuals liable for the full amount.
H.R. 5652 (Ryan)
Sequester Replacement Reconciliation Act of 2012. Passed the House by a vote of 218-199 on May 10, 2012. H.R. 5652, which was
introduced pursuant to the reconciliation instructions in the House FY2013 budget resolution (H.Con.Res. 112), would have eliminated the
FY2013 sequestration of direct defense spending (as required under the Budget Control Act of 2011), reduced the FY2013 overal discretionary
cap by $19 billion, and implemented a series of mandatory program savings recommended by six House committees. Among its many
provisions, H.R. 5652 would have (1) eliminated al limits on repayment of any premium credit overpayment, making individuals liable for the full
amount; (2) repealed the authority and appropriations for the exchange planning and establishment grants and rescinded all unobligated funds;
(3) repealed the authority and appropriations for the PPHF and rescinded all unobligated funds; (4) rescinded all remaining unobligated funds for
the CO-OP program; (5) extended by one year the disproportionate share hospital (DSH) al otment reduction imposed by the ACA; and (6)
repealed the ACA’s Medicaid maintenance of effort requirements.
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Bill (Sponsor)
Bill Title, House Vote, Summary of ACA Provisions
H.R. 4628 (Biggert)
Interest Rate Reduction Act. Passed the House by a vote of 215-195 on April 27, 2012. H.R. 4628 would have postponed by one year a
scheduled increase in Stafford education loan rates and, to offset the costs of that adjustment, repealed the authority and appropriations for the
PPHF and rescinded all unobligated funds. [Note: The one-year Stafford loan rate extension was incorporated as Division F, Title III of MAP-21,
the surface transportation reauthorization bill (see entry for P.L. 112-141 in Table 1). The provision in H.R. 4628 to repeal the PPHF and
rescind al unobligated funds was not included in MAP-21.]
H.R. 5 (Gingrey)
Protecting Access to Healthcare Act. Passed the House by a vote of 223-181 on March 22, 2012. Title II of H.R. 5 would have repealed the
authority and appropriations for IPAB.
H.R. 1173 (Boustany)
Fiscal Responsibility and Retirement Security Act of 2012. Passed the House by a vote of 267-159 on February 1, 2012. H.R. 1173
would have repealed Title VIII of the ACA, the Community Living Assistance Services and Supports (CLASS) Act. [Note: P.L. 112-240, enacted
January 2, 2013, included a repeal of the CLASS Act; see Table 1.]
H.R. 358 (Pitts)
Protect Life Act. Passed the House by a vote of 251-172 on October 13, 2011. H.R. 358 would have prohibited using any funds authorized or
appropriated by the ACA to pay for an abortion or to pay for any part of the costs of a health plan that covers abortions, except if the
pregnancy is the result of rape or incest, or the life of the pregnant female is at risk unless an abortion is performed. It would have required
insurers that offer plans through the exchanges that cover abortion services to offer identical plans that do not cover abortion services. It also
would have prohibited federal, state, or local government programs that receive ACA funding from discriminating against health care entities
that refuse to provide abortion services or abortion training.
H.R. 1216 (Guthrie)
A bill to convert funding for graduate medical education (GME) in qualified teaching health centers (THCs) to an
authorization of appropriations.
Passed the House by a vote of 234-185 on May 25, 2011. H.R. 1216 would have replaced the appropriation
for GME payments to THCs with an authorization of appropriations for each of FY2012 through FY2015, and rescinded al unobligated funds. It
would have prohibited the GME funds from being used to provide abortions, except in cases of rape or incest or when the woman’s life is in
danger.
H.R. 1214 (Burgess)
A bill to repeal ACA funding for school-based health center (SBHC) construction. Passed the House by a vote of 235-191 on May 4,
2011. H.R. 1214 would have repealed the authority and appropriations for SBHC construction grants and rescinded al unobligated funds.
H.R. 1213 (Upton)
A bill to repeal ACA funding for health insurance exchanges. Passed the House by a vote of 238-183 on May 3, 2011. H.R. 1213 would
have repealed the authority and appropriations for state exchange planning and establishment grants and rescinded al unobligated funds.
H.R. 1217 (Pitts)
A bill to repeal the Prevention and Public Health Fund (PPHF). Passed the House by a vote of 236-183 on April 13, 2011. H.R. 1217
would have repealed the authority and appropriations for the PPHF and rescinded all unobligated funds.
H.R. 2 (Cantor)
Repealing the Job-Killing Health Care Law Act. Passed the House by a vote of 245-189 on January 19, 2011. It was offered as an
amendment during Senate floor debate on an unrelated bill (S. 223) and rejected on a procedural motion by a vote of 47-51. H.R. 2 would have
repealed the ACA in its entirety and restored the provisions of law amended or repealed by the ACA as if it had not been enacted.
Source: Prepared by the Congressional Research Service based on the text of the bills listed in the table.



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CRS-15

Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act

Author Contact Information

C. Stephen Redhead
Janet Kinzer
Specialist in Health Policy
Information Research Specialist
credhead@crs.loc.gov, 7-2261
jkinzer@crs.loc.gov, 7-7561


Congressional Research Service
16