The ACA after the expiry of the budget reconciliation.

Republicans, from President Donald Trump down, have predicted the imminent demise of the Affordable Care Act (ACA) and its health insurance marketplaces, but so far their efforts to dismantle the law have proven far more vulnerable. Next month, enrolment begins for health insurance coverage in 2018. As the programme enters its fifth year, the rate of uninsured people in the USA has hit an all-time low, and after several attempts, the ACA repeal is on hold, if not abandoned. At the same time, there is growing acknowledgment across the political spectrum that the ACA needs some improvements, and faltering bipartisan negotiations in the Senate Health, Education, Labor and Pensions committee have resumed. “It’s been a big problem, up to now, that neither party has been interested in opening the ACA for meaningful improvement”, said David Barbe, a family physician and president of the American Medical Association (AMA), representing over 220 000 medical students, residents, and physicians. But any fixes will probably come too late to affect 2018 insurance policies, which were finalised last month. Senate Republicans had hoped to muster the 50 votes needed to pass legislation repealing and replacing the ACA (with Vice President Mike Pence casting the deciding 51st vote), before a procedural strategy known as the budget reconciliation, which provides a temporary exception to the 60 votes that are usually required to approve legislation, expired at midnight on Sept 30, when the federal government’s fiscal year ended. But the repeal bills failed to gain enough support before then. At the beginning of the final week, Capitol police arrested 181 people with disabilities and their supporters, as they protested outside the only hearing on a repeal legislation, sponsored by South Carolina Senator Lindsey Graham and Louisiana Senator Bill Cassidy.