This week the CEOs of major pharmaceutical firms will come to Capitol Hill to defend their products’ prices. The hearing before the Senate Finance Committee is expected to produce rhetorical fireworks, particularly given the national furor over rising drug prices.

This video features five dramatic moments from past congressional showdowns over health care.

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Late Thursday evening, the White House announced it would cease key payments to insurers. Earlier on Thursday, Trump signed an aimed at giving people who buy their own insurance easier access to different types of health plans that were limited under the ACA rules set by the Obama administration.

“This is promoting health care choice and competition all across the United States,” Trump said at the signing ceremony. “This is going to be something that millions and millions of people will be signing up for, and they’re going to be very happy.”

The subsidy payments, known as “cost-sharing reductions,” are payments to insurers to reimburse them for discounts they give policyholders with incomes under 250 percent of the federal poverty line, for an individual. Those discounts shield these lower-income customers from out-of-pocket expenses, such as deductibles or copayments. These subsidies have been the subject of a lawsuit that is ongoing.

The cost-sharing reductions are separate from the tax credit subsidies that help millions of people pay their premiums. Those are not affected by Trump’s decision.

Some of Trump’s actions could have an immediate effect on the enrollment for 2018 ACA coverage that starts Nov. 1. Here are five things you should know.

1. The executive order does not make any immediate changes.

Technically, Trump ordered the departments of Labor, Health and Human Services and Treasury within 60 days to “consider proposing regulations or revising guidance, to the extent permitted by law,” on several different options for expanding the types of plans individuals and small businesses could purchase. Among his suggestions to the department are broadening rules to allow more small employers and other groups to form what are known as “association health plans” and to sell low-cost, short-term insurance. There is no guarantee, however, that any of these plans will be forthcoming. In any case, the process to make them available could take months.

2. The cost-sharing reduction changes ARE immediate but might not affect the people you expect.

Cutting off payments to insurers for the out-of-pocket discounts they provide to moderate-income policyholders does not mean those people will no longer get help. The law, and insurance company contracts with the federal government, require those discounts be granted.

That means insurance companies will have to figure out how to recover the money they were promised. They could raise premiums (and many are raising them already). For the majority of people who get the separate subsidies to help pay their premiums, those increases will be borne by the federal government. Those who will be hit hardest are the who buy their own individual insurance but earn too much to get federal premium help.

Insurers could also simply drop out of the ACA entirely. That would affect everyone in the individual market and could leave some counties with no insurer for next year. Insurers could also sue the government, and most experts .

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The changes were hailed by religious groups, including the U.S. Conference of Catholic Bishops, it was “a return to common sense, long-standing federal practice and peaceful coexistence between church and state.” But others, including the National Women’s Law Center, said they plan to file suit against the rules. The National Health Law Program said that the rules appeared “legally suspect.”

Here are some frequently asked questions and answers about the new rules.

Q: What is the new policy?

Trump administration they are significantly rolling back rules requiring many insurers to provide contraceptive coverage to women. Employers with a moral or religious objection to contraceptive services will be allowed to stop offering that coverage.

Under provisions of the Affordable Care Act, the Obama administration had requiring most plans to cover all contraception methods that have been approved by the Food and Drug Administration with no out-of-pocket cost to women.ÌýThe provision does not cover plans that have a grandfathered status under the law.

That guarantee was whittled back through regulation and court actions to exempt some religious-based organizations, such as churches, and some privately held companies in which the owners have strong objections to contraception. Other nonprofit religious employers were offered an accommodation so that they didn’t contract or pay for the insurance coverage for their workers.

The rules unveiled Friday expand those exemptions to any nonprofit organizations and for-profit companies with firm religious opposition, as well as health plans provided to students at colleges with a religious affiliation. A second rule extends an exemption to organizations and privately held companies that have moral objections.

If an employer doesn’t have any moral or religious objections to contraception coverage, current ACA guidelines still apply. Federal policy for programs that offer free or subsidized coverage to low-income women also will not change.

The rules become effective as soon as they are published in the Federal Register, which is expected soon. View them online and .

Q:ÌýWho is covered by the ruling?

Exactly who will be affected is in dispute.

In a , the Department of Health and Human Services said that the rules “will not affect over 99.9 percent” of the 165 million women in the United States. The exemptions announced Friday, HHS said, “may impact only about 200 entities, the number that filed lawsuits based on religious or moral objections.”

Groups that favor the ACA’s contraception coverage say the impact will be far larger.

“The Trump administration just took direct aim at birth control coverage for 62 million women,” Cecile Richards, president of the Planned Parenthood Federation of America, said in a statement. “With this rule in place, any employer could decide that their employees no longer have health insurance coverage for birth control.”

Mara Gandal-Powers, a senior counsel at the National Women’s Law Center, said that even though many employers will not change their coverage, women in some places could find it difficult to get the health care they need.

HHS estimated in 2015 that were covered by policies that provide no-cost contraceptives. The number of women paying for contraceptives fell from nearly 21 percent in 2012 to by 2014, according to the Kaiser Family Foundation. Ìý(Kaiser Health News is an editorially independent program of the foundation.)

While some employers will be exempt from the ACA rules covering contraception, they may not be exempt from applicable state laws. Eight states currently have laws to employees, while another 20 states have laws requiring coverage of prescription contraceptives with the option of asking employees to pay some of the cost. Those state laws still apply, said Laurie Sobel, associate director of women’s health policy at the Kaiser Family Foundation.

Q: How have the courts ruled previously on the ACA and contraception coverage?

In 2014, the Supreme Court voted 5-4 to allow a key exemption to the health law’s contraception coverage requirements when it ruled that closely held, for-profit businesses could assert a religious objection to the Obama administration’s regulations.

The court’s majority said that the companies that filed suit — Hobby Lobby Stores, a nationwide chain of 500 arts-and-crafts stores, and Conestoga Wood Specialties, a custom cabinet manufacturer — did not have to offer female employees all of the Food and Drug Administration-approved contraceptives as part of a package of preventive services that must be covered without copays or deductibles under the law. The companies had argued that several types of contraceptives violate their owners’ religious beliefs.

The companies are family-owned, and they said that the health law’s contraception requirement violated their religious views. While both employers’ health plans covered some forms of birth control, they found some forms of emergency contraceptives objectionable, such as Plan B and Ella that can prevent a pregnancy if taken within a short window after unprotected sex. They said these contraceptive methods prevent a fertilized egg from implanting in the woman’s uterus and therefore are a type of abortion.

In another lawsuit, religious groups, including the Little Sisters of the Poor, an order of Roman Catholic nuns, said that complying with an Obama administration accommodation for religious-affiliated groups violated their religious views. In May 2016, the Supreme Court sent that lawsuit back to the lower courts to see if a compromise was possible.

Q: How does the Obama administration’s accommodation work?

The Obama administration’s policy also did not apply to churches or houses of worship. And in response to protests from other nonprofit religious organizations — such as church-affiliated hospitals or schools — officials set up an accommodation that allowed those employers to not contract for contraceptive coverage as part of the insurance that they offered workers. Instead, the insurance plan that served their employees would provide coverage, at no cost, to the workers. Some of those groups, such as the Little Sisters of the Poor, objected to this setup and challenged the policy in court.

KHN’s coverage of women’s health care issues is supported in part by .

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By 2026, an estimated 49 million people would be uninsured, compared with about 28 million who would lack coverage under current law.

The Senate’s bill — , which GOP leaders hope to put to a vote later this week —Ìýcomes nearly two months after the House passed its plan to overhaul the Affordable Care Act. That measure and leave an additional 23 million people without coverage in 2026, according to CBO. It would reduce the federal .

Earlier in the day, before the nonpartisan budget office’s score was released, Senate Majority Leader Mitch McConnell (R-Ky.) described the GOP plan as preserving “access to care for patients with preexisting conditions.” He also said it would “strengthen Medicaid,” give “Americans more power to control and reduce their medical costs and out-of-pocket expenses” and give “states significant new tools to drive down premiums.”

Yet it was unclear if Republicans, who have a razor-thin Senate majority, could garner the 50 votes necessary for the measure to pass. The budget office’s findings added to this uncertainly.

Sen. Susan Collins (R-Maine), a moderate who has been on the fence about the bill, tweeted late this afternoon that she could not support the current bill based on the CBO score. “I want to work with my GOP and Democratic colleagues to fix the flaws in ACA. CBO analysis shows Senate bill won’t do it. I will vote no” on bringing the bill to the Senate floor, she announced.

Senate Democrats were also swift to react.

“The CBO report should be the end of the road for Trumpcare,” tweeted Senate Minority Leader Chuck Schumer (D-N.Y.). And, in a statement, Sen. Ron Wyden (D-Ore.) said it was “abundantly clear [Republicans] are going in the wrong direction.”

Sen. Bernie Sanders (I-Vt.) pointed to the analysis and said the GOP plan was “a cynical and immoral proposal.”

Detailing The Medicaid Numbers

Under the GOP measure, federal spending on Medicaid would drop by 26 percent over current spending projections, or $772 billion, over the next decade, according to the analysis.

The drop in spending would occur mainly because the Senate plan phases out federal funds for states to expand Medicaid and it puts annual caps on federal Medicaid dollars to states. Currently, federal Medicaid matching payments to states are open-ended.

By 2026, the budget office predicted, 15 million fewer people would be enrolled in Medicaid than projected under the ACA. Currently, more than low-income and disabled people are Medicaid beneficiaries.

How Medicaid beneficiaries are affected by these caps depends on how states respond to them, the CBO notes.

“With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes,” according to the analysis.

The Medicaid funding provisions are a key reason several influential health groups say they cannot support the bill.

“Access to care for some of the most vulnerable members of our society — including those who require treatment for opioid-use disorder — would be endangered by the Senate proposal’s arbitrary, unsustainable, and shortsighted formula for funding Medicaid,” David Barbe, president of the American Medical Association, said in a statement posted on the organization’s website.

And even before the CBO report was issued, the National Association of Medicaid Directors was on record with its concerns. “The Senate bill does formalize several critical administrative and regulatory improvements, such as giving Medicaid Directors a seat at the table in the development of regulations that impact how the program is run, and the pathway to permanency for certain waiver programs,” the group said. “However, no amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill.”

Other organizations, such as Families USA and the American Public Health Association, said the CBO’s findings show the Senate proposal did “devastating harm” and would “seriously jeopardize the health of America.”

Cost And Coverage

The budget scorekeepers also concluded that, for the individual insurance market, premium costs would go down under the Senate plan, but so would the amount of coverage provided.

Because these plans “would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law,” CBO said.

In 2017, an estimated people bought health coverage through the ACA’s marketplaces. Most bought silver-level plans, which covered 70 percent of health care costs.

Under the Senate’s plan, the average premiums for an individual in 2020 would be about 30 percent lower. But these policies would cover about 58 percent of costs on average.

According to the CBO, “a combination of factors would lead to that decrease – most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.”

The CBO also analyzed the Senate bill provision that would allow states to use waivers to modify the health law’s that include items like prescription drugs, maternity coverage, mental health and substance abuse. In states where such waivers were granted, consumers could experience substantial cost increases for supplemental premiums or out-of-pocket spending, or choose to forgo services. Nearly half the population, the CBO estimates, would reside in states that seek these waivers.

In addition, the ACA’s ban on lifetime and annual limits on covered benefits would no longer apply to health benefits not defined as essential in a state.

Note: This story was updated to correct the party affiliation of Sen. Ron Wyden. He is a Democrat.Ìý

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House Speaker Paul Ryan pulled the bill from consideration after he rushed to the White House to tell President Donald Trump that there weren’t the 216 votes necessary for passage.

“We came really close today, but we came up short,” he told reporters at a hastily called news conference.

When pressed about what happens to the federal health law, he added, “Obamacare is the law of the land. … We’re going to be living with Obamacare for the foreseeable future.”

Trump laid the blame at the feet of Democrats, complaining that not one was willing to help Republicans on the measure, and he warned again that the Obamacare insurance markets are in serious danger. “Bad things are going to happen to Obamacare,” he told reporters at the White House. “There’s not much you can do to help it. I’ve been saying that for a year and a half. I said, look, eventually it’s not sustainable. The insurance companies are leaving.”

But he said the collapse of the bill might allow Republicans and Democrats to work on a replacement. “I honestly believe the Democrats will come to us and say, ‘Look, let’s get together and get a great health care bill or plan that’s really great for the people of our country,'” he said.

Ryan originally had hoped to hold a floor vote on the measure Thursday — timed to coincide with the seventh anniversary of the ACA — but decided to delay that effort because GOP leaders didn’t have enough “yes” votes. The House was in session Friday before his announcement while members debated the bill.

House Democratic leader Nancy Pelosi (Calif.) said the speaker’s decision to pull the bill “is pretty exciting for us …Ìýa victory for the Affordable Care Act, more importantly for the American people.”

The legislation was damaged by a variety of issues raised by competing factions of the party. Many members were nervous about reports by the showing that the bill would lead eventually to 24 million people losing insurance, while some moderate Republicans worried that would hurt low-income Americans.

At the same time, conservatives, especially the hard-right House Freedom Caucus that often has needled party leaders, complained that the bill kept too much of the ACA structure in place. They wanted a straight repeal of Obamacare, but party leaders said that couldn’t pass the Senate, where Republicans don’t have enough votes to stop a filibuster. They were hoping to use a complicated legislative strategy calledÌýÌýthat would allow them to repeal only parts of the ACA that affect federal spending.

The decision came after a chaotic week of negotiations, as party leaders sought to woo more conservatives. Trump personally lobbied 120 members through personal meetings or phone calls, according to a count provided Friday by his spokesman, Sean Spicer. “The president and the team here have left everything on the field,” Spicer said.

On Thursday evening, Trump dispatched Office of Management and Budget Director Mick MulvaneyÌýto tell his former House GOP colleagues that the president .ÌýIt was time to move on to other priorities, including tax reform, he told House Republicans.

“He said the president needs this, the president has said he wants a vote tomorrow, up or down. If for any reason it goes down, we’re just going to move forward with additional parts of his agenda. This is our moment in time,” Rep. Chris Collins (R-N.Y.), a loyal Trump ally, told reporters late Thursday. “If it doesn’t pass, we’re moving beyond health care. … We are done negotiating.”

Trump’s edict clearly irked some lawmakers, including the (R-N.C), whose group of more than two dozen members represented the strongest bloc against the measure.

“Anytime you don’t have 216 votes, negotiations are not totally over,” he told reporters who had surrounded him in a Capitol basement hallway as he headed in to the party’s caucus meeting.

Trump, Ryan and other GOP lawmakers tweaked their initial package in a variety of ways to win over both conservatives and moderates.ÌýBut every time one change was made to win votes in one camp, it repelled support in another.

The White House on Thursday accepted conservatives’ demands that the legislation strip federal guarantees of in insurance policies. But that was another problem for moderates, and Democrats suggested the provision would not survive in the Senate.

Republican moderates in the House — as well as the Senate — objected to the bill’s provisions that would to a set amount of funding for states that would also give governors and state lawmakers more flexibility over the program. Moderates also were concerned that the package’s tax credits would not be generous enough to help older Americans — who could be than their younger counterparts — afford coverage.

The House package also lost the support of key GOP allies, including the Club for Growth and Heritage Action. , patient and also opposed it.

But Ryan’s comments made clear how difficult this decision was. “This is a disappointing day for us,” he said. “Doing big things is hard. All of us. All of usÌý— myself included — we will need time to reflect on how we got to this moment, what we could have done to do it better.”

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The legislation would keep the health law’s provisions allowing adult children to stay on their parents’ health insurance plan until age 26 and prohibiting insurers from charging people with preexisting medical conditions more for coverage as long as they don’t let their insurance lapse.Ìý If they do, insurers can charge a flat 30 percent late-enrollment surcharge on top of the base premium, under the Republican bill.

In a statement, House Speaker Paul Ryan (R-Wis.) said the proposal would “drive down costs, encourage competition, and give every American access to quality, affordable health insurance. It protects young adults, patients with preexisting conditions, and provides a stable transition so that no one has the rug pulled out from under them.”

The GOP plan, as predicted, and would not enforce the so-called employer mandate, which requires certain employers to provide a set level of health coverage to workers or pay a penalty.

Democrats quickly condemned the bill. “Tonight, Republicans revealed a Make America Sick Again bill that hands billionaires a massive new tax break while shifting huge costs and burdens onto working families across American,” House Minority Leader Nancy Pelosi tweeted. “Republicans will force tens of millions of families to pay more for worse coverage — and push millions of Americans off of health coverage entirely.”

The legislation has been the focus of intense negotiations among different factions of the Republican Party and the Trump administration since January. The Affordable Care Act passed in 2010 without a single Republican vote, and the party has strongly denounced it ever since, with the House voting more than 60 times to repeal Obamacare. But more than 20 million people have gained coverage under the law, and President Donald Trump and some congressional Republicans have said they don’t want anyone to lose their insurance.

When Republicans took control of both Congress and the White House this year, they did not have an agreement on the path for replacement, with some lawmakers from states that have expanded Medicaid concerned about the effect of repeal and the party’s conservative wing pushing hard to jettison the entire law.

Sen. Rand Paul (R-Ky.), one of those favoring a full repeal, tweeted: “Still have not seen an official version of the House Obamacare replacement bill, but from media reports this sure looks like Obamacare Lite!”

Complicating the effort is the fact that Republicans have only 52 seats in the Senate, so they cannot muster the 60 necessary to overcome a Democratic filibuster. That means they must use a complicated legislative strategy called that allows them to repeal only parts of the ACA that affect federal spending.

Beginning in 2020, the GOP plan would provide tax credits to help people pay for health insurance based on household income and age, with a limit of $14,000 per family.ÌýEach member of the family would accumulate credits, ranging from $2,000 for an individual under 30 to $4,000 for people age 60 and older.ÌýThe credits would begin to diminish after individuals reached an income of $75,000 — or $150,000 for joint filers.

Consumers also would be allowed to put more money into tax-free health savings accounts and would lift the $2,500 cap on flexible savings accounts beginning in 2018.

The legislation would allow insurers to charge older consumers than younger people. The health law currently permits a 3-to-1 ratio.

Community health centers would receive $422 million in additional funding in 2017 under the legislation, which also places a and prohibits the use of tax credits to purchase health insurance that covers abortion.

Both the Energy and Commerce and Ways and Means Committees are scheduled to mark up the legislation Wednesday. The committees do not yet have any Congressional Budget Office analysis of how much the legislation would cost or how many people it would cover.

Party leaders have said they want to have the bill to President Trump next month.

In a statement, senior Democrats on both panels said the measure would charge consumers “more money for less care. It would dramatically drive up health care costs for seniors. And repeal would ration care for more than 70 million Americans, including seniors in nursing homes, pregnant women and children living with disabilities by arbitrarily cutting and capping Medicaid,”Ìýsaid Rep. Frank Pallone of New Jersey and Rep. Richard Neal of Massachusetts.

The House GOP plan makes dramatic changes to Medicaid, the state-federal health insurance program that covers 70 million low-income Americans. The program began in 1965 as an entitlement — which means federal and state funding is ensured regardless of cost and enrollment. But the Republican bill would cap federal funding for Medicaid for the first time.

The federal government picks up between half and 70 percent of Medicaid costs. The percentage varies based on the relative wealth of the state.

Under the GOP plan, federal funding would be based on what the government spent in the fiscal year that ended Sept. 30. Those amounts would be adjusted annually based on a state’s enrollment and medical inflation.

Currently, federal payments to states also take into account how generous the state’s benefits are and what rate it uses to pay providers. That means states like New York and Vermont get higher funding than states like Nevada and New Hampshire and those differences would be locked in for future years.

Republicans have pushed to cap federal funding to states in return for giving them more control in running the program.

The legislation also affects the health law’s expansion of Medicaid, in which the federal government provided enhanced funding to states to widen eligibility. The bill would also end that extra funding for anyone enrolling under the expansion guidelines starting in 2020. But the legislation would let states keep the extra funding Obamacare provided for individuals already in the expansion program who stay enrolled.

About 11 million Americans have gained Medicaid coverage since 2014.

Changing the expansion program is a delicate balance for the Republicans. Four GOP senators from states that took that option said Monday they would oppose any legislation that repealed the expansion.

“We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services,” Sens. Rob Portman of Ohio, Shelley Moore CapitoÌýof West Virginia, Cory GardnerÌýof Colorado andÌýLisa MurkowskiÌýof Alaska wrote to Majority Leader Mitch McConnell.

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The Affordable Care Act of course affected premiums and insurance purchasing. It guaranteed people with pre-existing conditions could buy health coverage and allowed children to stay on parents’ plans until age 26. But the roughly 2,000-page bill also included a host of other provisions that affect the health-related choices of nearly every American.

Some of these measures are evident every day. Some enjoy broad support, even though people often don’t always realize they spring from the statute.

In other words, the outcome of the repeal-and-replace debate could affect more than you might think, depending on exactly how the GOP congressional majority pursues its goal to do away with Obamacare.

No one knows how far the effort will reach, but here’s a sampling of sleeper provisions that could land on the cutting-room floor:

CALORIE COUNTS AT RESTAURANTS AND FAST FOOD CHAINS

Feeling hungry? The law tries to give you more information about what that burger or muffin will cost you in terms of calories, part of an effort to combat the ongoing obesity epidemic. Under the ACA, most restaurants and fast food chains with at least 20 stores must of their menu items. Several states, including New York, already had similar rules before the law. Although there was some pushback, the rule had industry support, possibly because posting calories was seen as less onerous than such things as taxes on sugary foods or beverages. The final rule went into effect in December after a one-year delay. One thing that is still unclear: Does simply seeing that a particular muffin has more than 400 calories cause consumers to choose carrot sticks instead?Ìý Results are mixed. One large meta-analysis done before the law went into effect didn’t show a significant reduction in calorie consumption, although the authors concluded that is “a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories.”

PRIVACY PLEASE: WORKPLACE REQUIREMENTS FOR BREAST-FEEDING ROOMS

Breast feeding, but going back to work? The law requires employers to provide women to express milk for up to a year after giving birth and provide someplace — other than a bathroom — to do so in private. In addition, most health plans breastfeeding support and equipment, such as pumps, without a patient co-payment.

LIMITS ON SURPRISE MEDICAL COSTS FROM HOSPITAL EMERGENCY ROOM VISITS

If you find yourself in an emergency room, short on cash, uninsured or not sure if your insurance covers costs at that hospital, the law provides some . If you are in a hospital that is not part of your insurer’s network, the Affordable Care Act requires all health plans to charge consumers the same co-payments or co-insurance for out-of-network emergency care as they do for hospitals within their networks. Still, the hospital could “balance bill” you for its costs —Ìýincluding ER care — that exceed what your insurer reimburses it.

If it’s a non-profit hospital — and about 78 percent of all hospitals are — the law requires it to post online a written , spelling out whether it offers free or discounted care and the eligibility requirements for such programs. While not prescribing any particular set of eligibility requirements, the law requires hospitals to charge lower rates to patients who are eligible for their financial assistance programs. That’s compared with their gross charges, also known as chargemaster rates.

NONPROFIT HOSPITALS’ COMMUNITY HEALTH ASSESSMENTS

The health law also requires non-profit hospitals to the billions of dollars in tax exemptions they receive by demonstrating how they go about trying to improve the health of the community around them.

Every three years, these hospitals have to perform a community needs assessment for the area the hospital serves. They also have to develop — and update annually — strategies to meet these needs. The hospitals then must provide documentation as part of their annual reporting to the Internal Revenue Service. Failure to comply could leave them liable for a $50,000 penalty.

A WOMAN’S RIGHT TO CHOOSE … HER OB/GYN

Most insurance plans must allow women to seek care from an obstetrician/gynecologist without having to get a referral from a primary care physician. While the majority of states already had such protections in place, those laws did not apply to self-insured plans, which are often offered by large employers. The health law to all new plans. Proponents say direct access makes it easier for women to seek not only reproductive health care, but also related screenings for such things as high blood pressure or cholesterol.

AND WHAT ABOUT THOSE THERAPY COVERAGE ASSURANCES FOR FAMILIES WHO HAVE KIDS WITH AUTISM?

Advocates for children with autism and people with degenerative diseases argued that many insurance plans did not provide care their families needed. That’s because insurers would cover rehabilitation to help people regain functions they had lost, such as walking again after a stroke, but not care needed to either gain functions patients never had, such speech therapy for a child who never learned how to talk, or to maintain a patient’s current level of function. The law requires plans to offer coverage for such treatments, dubbed , as part of the essential health benefits in plans sold to individuals and small groups.

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Department of Health and Human Services Secretary Sylvia Burwell Wednesday acknowledged that the Affordable Care Act’s fourth enrollment season, scheduled to begin Nov. 1 and run until Jan. 31, is a pivotal time for President Barack Obama’s signature domestic policy achievement.

“Building a new market is never easy,” she said in remarks at HHS headquarters, where she also unveiled ACA enrollment estimates for the upcoming year. “We expect this to be a transition period for the marketplace. Issuers are adjusting their prices, bringing them in line with actual data on costs.”ÌýBurwell’s comments foreshadowed the Ìýfor the next enrollment season. Federal officials are likely to release those numbers just days before the presidential election that could determine whether the ACA is repealed or revamped.

While the health law hasn’t been a predominant issue in the current election season, it has been at the center of a bitter battle between political parties since it was passed in 2010. The House of Representatives has voted to repeal all or part of the measure and the law has survived some court challenges and faces others.

Burwell noted those fights when talking about issues that have arisen in the implementation of the law that need to be resolved and said that “it also hasn’t helped that at nearly every turn, we’ve had to overcome partisan attempts to repeal and undermine the law through legislation and litigation.”

Enrollment in the state and federal marketplaces is expected to grow by about a million people next year —Ìýfrom about 12.7 million to 13.8 million, according to released Wednesday. The number of consumers who actually pay premiums and stay in the market is expected to average about 10.5 million per month this year and about in 2017.

Consumers flow in and out of ACA plans because they change jobs, get coverage from other sources and face other factors that affect where and how they enroll in health insurance, including affordability. About 9.2 million of the 13.8 million who now have ACA coverage are expected to reenroll, according to HHS.

This year’s enrollment period is focused on signing up healthier consumers —Ìýincluding the “young invincibles” between the ages of 18 and 34 who tend to have fewer ailments —Ìýand making the enrollment process faster and simpler. They will also remind consumers of the penalty for not having coverage, which . The flat penalty will be adjusted for inflation in 2017.

Federal officials are also focusing enrollment efforts on the 5.1 million Americans who are eligible to purchase health care coverage on the exchanges but do so elsewhere, according to HHS figures.ÌýOf that group, 2.5 million people could be eligible for the law’s financial assistance if they sign up for coverage during open enrollment, . A from the Kaiser Family Foundation found that 11.7 million people who remain without health insurance are eligible for Medicaid in their state or for tax credits to purchase health insurance through their state’s ACA marketplace. (KHN is an editorially independent program of the Kaiser Family Foundation.)

The outcome of the November elections may well determine the future of the ACA as much as the willingness of insurers to offer coverage and consumers to enroll in the plans. Republican presidential nominee Donald Trump has promised to the law, while Democratic nominee Hillary Clinton has said she wants to , making it more affordable for consumers who don’t qualify for subsidies and struggle to afford coverage.

Burwell called on Congress to work with her and the Obama administration to make needed changes to the law. “To make more substantial changes, like a public option to encourage competition, we’ll need cooperation from Congress,” she said. “And we are hopeful that soon, we’ll see more bipartisan efforts to make improvement.”

Bipartisan cooperation most likely won’t happen until the next Congress, if then. Much will depend on who is in power, whether GOP leaders think the ACA is still a potent political issue and how willing Democrats will be to make changes that might appeal to Republicans.

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Even as the cost of EpiPens dramatically rose, so too did the number of prescriptions written for patients in Medicare, sending spending by the program skyrocketing nearly 1,100 percent from 2007 to 2014, a shows.

During the same period, the total number of Medicare beneficiaries using EpiPens climbed 164 percent, from nearly 80,000 users in 2007 to more than 211,000 in 2014, according to the analysis by the Kaiser Family Foundation. While the report does not delve into what’s behind the increase, factors could include increased awareness among people with allergies, marketing efforts and access to insurance coverage.

The abrupt rise is notable because many people think that life-threatening allergies are less common among the elderly. In addition, epinephrine —Ìýthe active ingredient in EpiPens —Ìýcan pose greater risks to older adults. Food and Drug Administration urges caution when prescribing to this age group.

“That level of increase gives me pause,” said Martha Twaddle, senior medical officer for Illinois at Aspire Health, which provides home-based supportive care for people with serious illness.Ìý She did not work on the study. Epinephrine —Ìýthe active ingredient in EpiPens —Ìýcan cause side effects including chest pain, rapid increase in blood pressure or irregular heart rhythms, which could be fatal, for people with certain medical conditions, including heart disease.

The foundation study comes amid ongoing scrutiny —Ìýincluding Wednesday by Mylan CEO Heather Bresch —Ìýover EpiPen price increases. (Kaiser Health News is an editorially independent program of the Foundation.)

EpiPens are used in cases of severe allergic reactions.ÌýCosts for a two-pack of the pens has gone from about $94 in January 2007 to $609 in May of this year.ÌýIn response to criticism of its price increase, Mylan announced in late August that it would make a and price it at half of its current brand name price.

The new numbers from Medicare could add fuel to the debate over these price increases and voters’ demands that Congress take action to roll back the cost of the popular medication.

The health insurance program for senior citizens and disabled people spent about $6.4 million on the devices in 2007, but spent $75.3 million in 2014, with sharp price hikes by the manufacturer driving much of the increase. Those figures reduce the amount spent based on estimates of how much Medicare saved in rebates from manufacturers, although the agency would not disclose the exact amounts.

Still, when patients show up in emergency rooms with life-threatening allergic reactions, epinephrine is a first line of defense, said Robert Glatter, emergency room physician at Lenox Hill Hospital in Manhattan. Those whose allergic reaction isn’t immediately life threatening would more likely get a mix of steroids and antihistamines, he said.

All patients with suspected severe allergic reactions —Ìýeven the elderly —Ìýare given either a prescription or an actual epinephrine auto injector upon discharge, he said.

“We tell them to have it and use it if they have a lip or tongue swelling, shortness of breath, a skin rash [or other symptoms] of a problem,” said Glatter, adding that adults tend to become more susceptible to food allergies as they age.

Increased awareness among doctors and patients about the importance of epinephrine could account for some of the increase seen in the study, said Richard Lockey, a past president of both the World Allergy Organization and the American Academy of Allergy, Asthma & Immunology.

“Most people survive an allergic reaction … the people who don’t survive are those who don’t get epinephrine or don’t get it soon enough,” said Lockey, who says it is necessary to balance this idea with the possible risks epinephrine poses for older patients. “It’s a matter of clinical judgment.”

Although Medicare is generally thought of as the government health program for older people, about 16 percent —Ìýor 9.1 million beneficiaries —Ìýare younger than 65. They are generally disabled or have kidney problems requiring dialysis. According to foundation researchers, although the majority of users were older than 65, a disproportionate share – 35 percent — of the EpiPen users were younger than 65. Additionally, 26 percent were between 65 and 69. Use fell off with age, with only 15 percent of the users being between ages 75-85.

“You can come up with a ton of reasons why the under-65 population might see an increase in EpiPen use,” said James Goodwin, an expert in geriatric medicine at the University of Texas Medical Branch in Galveston. He did not work on the study.

As for the overall increase, Goodwin said there are likely many factors and it isn’t necessarily evidence of overutilization. Still, Goodwin says he specializes in patients older than age 80 and has never prescribed an EpiPen, nor had three of his colleagues, who work with slightly younger elderly patients.

One geriatrician said he has patients who are on it with prescriptions from their allergists, who weigh the pros and cons of having the drug. Those physicians “are the ones to say your allergy is serious enough to potentially become life threatening.”

At the American Geriatrics Society, epinephrine is not included on the , said Nicole Brandt, a professor at the School of Pharmacy at the University of Maryland.

“When you look at in context of someone having a severe anaphylactic reaction, which is life threatening, you want access to treatment,” said Brandt. She said doctors should caution patients about the appropriate use of the devices and encourage them to seek additional medical attention if they experience side effects.

She suggested the increase in Medicare prescriptions seen in the study reflects access to insurance more than overuse.

Since Medicare drug plans cover part of enrollees’ total drug costs, beneficiaries in prescription drug plans pay less that the full retail price. But beneficiaries still paid significantly more of their own money for EpiPens during the seven-year period studied in the report. Average out-of-pocket spending for beneficiaries with Medicare drug coverage nearly doubled for each EpiPen, from $30 to $56. The report does not include price increases beyond 2014.

Still, those costs are far less than what some people with private insurance might pay, particularly those with high deductibles. As a result, at least one doctor —Ìýgeriatrician David Barile from Princeton, New JerseyÌý—Ìýwho did not work on the study, speculated that the rise in Medicare use of EpiPens might simply be older people getting them for their grandchildren.

Liz Szabo contributed to this report.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the .

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In addition, HHS is focusing on outreach efforts to get those still uninsured —Ìýespecially younger and healthier individuals —Ìýto enroll when the marketplaces open on Nov. 1, she told reporters during a briefing at HHS.Ìý Potential enrollees under 34 are “driven by deadlines” and often enroll closer to the end of the open enrollment period, Burwell said.

Three of the nation’s largest health insurers — Aetna, UnitedHealthcare and Humana — have announced they will sell individual plans in 2017. So, too, will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

While some consumers will and for coverage, 85 percent of exchange enrollees received tax credits to help offset the rise in premiums, Burwell said.Ìý She said she continues to talk with insurers and state insurance commissioners to encourage greater participation in the marketplaces.

HHS also recently proposed to reflect insurers’ concerns, such as how to better account for individuals who aren’t enrolled in a health plan for an entire year, starting in 2017. ÌýOther steps include better use of drug utilization data and how to spread the risk of high-cost enrollees in 2018.

Burwell also mentioned HHS is seeking to increase enrollment by working with the Internal Revenue Service to contact people who paid a penalty for not having coverage and providing information about how to enroll on the exchanges. HHS and other federal agencies have also worked to reduce “data matching” errors that may have prevented eligible people from signing up for coverage.

Meanwhile, Burwell urged lawmakers returning to Capitol Hill next week to move quickly on a bipartisan basis to pass new funding to fight the .Ìý “This is an emergency … this is a national issue,” Burwell said.

Earlier this week, the director of the federal Centers for Disease Control and Prevention, Dr. Tom Frieden, warned that federal funds to fight the Zika virus .

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This week the CEOs of major pharmaceutical firms will come to Capitol Hill to defend their products’ prices. The hearing before the Senate Finance Committee is expected to produce rhetorical fireworks, particularly given the national furor over rising drug prices.

This video features five dramatic moments from past congressional showdowns over health care.

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Late Thursday evening, the White House announced it would cease key payments to insurers. Earlier on Thursday, Trump signed an aimed at giving people who buy their own insurance easier access to different types of health plans that were limited under the ACA rules set by the Obama administration.

“This is promoting health care choice and competition all across the United States,” Trump said at the signing ceremony. “This is going to be something that millions and millions of people will be signing up for, and they’re going to be very happy.”

The subsidy payments, known as “cost-sharing reductions,” are payments to insurers to reimburse them for discounts they give policyholders with incomes under 250 percent of the federal poverty line, for an individual. Those discounts shield these lower-income customers from out-of-pocket expenses, such as deductibles or copayments. These subsidies have been the subject of a lawsuit that is ongoing.

The cost-sharing reductions are separate from the tax credit subsidies that help millions of people pay their premiums. Those are not affected by Trump’s decision.

Some of Trump’s actions could have an immediate effect on the enrollment for 2018 ACA coverage that starts Nov. 1. Here are five things you should know.

1. The executive order does not make any immediate changes.

Technically, Trump ordered the departments of Labor, Health and Human Services and Treasury within 60 days to “consider proposing regulations or revising guidance, to the extent permitted by law,” on several different options for expanding the types of plans individuals and small businesses could purchase. Among his suggestions to the department are broadening rules to allow more small employers and other groups to form what are known as “association health plans” and to sell low-cost, short-term insurance. There is no guarantee, however, that any of these plans will be forthcoming. In any case, the process to make them available could take months.

2. The cost-sharing reduction changes ARE immediate but might not affect the people you expect.

Cutting off payments to insurers for the out-of-pocket discounts they provide to moderate-income policyholders does not mean those people will no longer get help. The law, and insurance company contracts with the federal government, require those discounts be granted.

That means insurance companies will have to figure out how to recover the money they were promised. They could raise premiums (and many are raising them already). For the majority of people who get the separate subsidies to help pay their premiums, those increases will be borne by the federal government. Those who will be hit hardest are the who buy their own individual insurance but earn too much to get federal premium help.

Insurers could also simply drop out of the ACA entirely. That would affect everyone in the individual market and could leave some counties with no insurer for next year. Insurers could also sue the government, and most experts .

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The changes were hailed by religious groups, including the U.S. Conference of Catholic Bishops, it was “a return to common sense, long-standing federal practice and peaceful coexistence between church and state.” But others, including the National Women’s Law Center, said they plan to file suit against the rules. The National Health Law Program said that the rules appeared “legally suspect.”

Here are some frequently asked questions and answers about the new rules.

Q: What is the new policy?

Trump administration they are significantly rolling back rules requiring many insurers to provide contraceptive coverage to women. Employers with a moral or religious objection to contraceptive services will be allowed to stop offering that coverage.

Under provisions of the Affordable Care Act, the Obama administration had requiring most plans to cover all contraception methods that have been approved by the Food and Drug Administration with no out-of-pocket cost to women.ÌýThe provision does not cover plans that have a grandfathered status under the law.

That guarantee was whittled back through regulation and court actions to exempt some religious-based organizations, such as churches, and some privately held companies in which the owners have strong objections to contraception. Other nonprofit religious employers were offered an accommodation so that they didn’t contract or pay for the insurance coverage for their workers.

The rules unveiled Friday expand those exemptions to any nonprofit organizations and for-profit companies with firm religious opposition, as well as health plans provided to students at colleges with a religious affiliation. A second rule extends an exemption to organizations and privately held companies that have moral objections.

If an employer doesn’t have any moral or religious objections to contraception coverage, current ACA guidelines still apply. Federal policy for programs that offer free or subsidized coverage to low-income women also will not change.

The rules become effective as soon as they are published in the Federal Register, which is expected soon. View them online and .

Q:ÌýWho is covered by the ruling?

Exactly who will be affected is in dispute.

In a , the Department of Health and Human Services said that the rules “will not affect over 99.9 percent” of the 165 million women in the United States. The exemptions announced Friday, HHS said, “may impact only about 200 entities, the number that filed lawsuits based on religious or moral objections.”

Groups that favor the ACA’s contraception coverage say the impact will be far larger.

“The Trump administration just took direct aim at birth control coverage for 62 million women,” Cecile Richards, president of the Planned Parenthood Federation of America, said in a statement. “With this rule in place, any employer could decide that their employees no longer have health insurance coverage for birth control.”

Mara Gandal-Powers, a senior counsel at the National Women’s Law Center, said that even though many employers will not change their coverage, women in some places could find it difficult to get the health care they need.

HHS estimated in 2015 that were covered by policies that provide no-cost contraceptives. The number of women paying for contraceptives fell from nearly 21 percent in 2012 to by 2014, according to the Kaiser Family Foundation. Ìý(Kaiser Health News is an editorially independent program of the foundation.)

While some employers will be exempt from the ACA rules covering contraception, they may not be exempt from applicable state laws. Eight states currently have laws to employees, while another 20 states have laws requiring coverage of prescription contraceptives with the option of asking employees to pay some of the cost. Those state laws still apply, said Laurie Sobel, associate director of women’s health policy at the Kaiser Family Foundation.

Q: How have the courts ruled previously on the ACA and contraception coverage?

In 2014, the Supreme Court voted 5-4 to allow a key exemption to the health law’s contraception coverage requirements when it ruled that closely held, for-profit businesses could assert a religious objection to the Obama administration’s regulations.

The court’s majority said that the companies that filed suit — Hobby Lobby Stores, a nationwide chain of 500 arts-and-crafts stores, and Conestoga Wood Specialties, a custom cabinet manufacturer — did not have to offer female employees all of the Food and Drug Administration-approved contraceptives as part of a package of preventive services that must be covered without copays or deductibles under the law. The companies had argued that several types of contraceptives violate their owners’ religious beliefs.

The companies are family-owned, and they said that the health law’s contraception requirement violated their religious views. While both employers’ health plans covered some forms of birth control, they found some forms of emergency contraceptives objectionable, such as Plan B and Ella that can prevent a pregnancy if taken within a short window after unprotected sex. They said these contraceptive methods prevent a fertilized egg from implanting in the woman’s uterus and therefore are a type of abortion.

In another lawsuit, religious groups, including the Little Sisters of the Poor, an order of Roman Catholic nuns, said that complying with an Obama administration accommodation for religious-affiliated groups violated their religious views. In May 2016, the Supreme Court sent that lawsuit back to the lower courts to see if a compromise was possible.

Q: How does the Obama administration’s accommodation work?

The Obama administration’s policy also did not apply to churches or houses of worship. And in response to protests from other nonprofit religious organizations — such as church-affiliated hospitals or schools — officials set up an accommodation that allowed those employers to not contract for contraceptive coverage as part of the insurance that they offered workers. Instead, the insurance plan that served their employees would provide coverage, at no cost, to the workers. Some of those groups, such as the Little Sisters of the Poor, objected to this setup and challenged the policy in court.

KHN’s coverage of women’s health care issues is supported in part by .

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By 2026, an estimated 49 million people would be uninsured, compared with about 28 million who would lack coverage under current law.

The Senate’s bill — , which GOP leaders hope to put to a vote later this week —Ìýcomes nearly two months after the House passed its plan to overhaul the Affordable Care Act. That measure and leave an additional 23 million people without coverage in 2026, according to CBO. It would reduce the federal .

Earlier in the day, before the nonpartisan budget office’s score was released, Senate Majority Leader Mitch McConnell (R-Ky.) described the GOP plan as preserving “access to care for patients with preexisting conditions.” He also said it would “strengthen Medicaid,” give “Americans more power to control and reduce their medical costs and out-of-pocket expenses” and give “states significant new tools to drive down premiums.”

Yet it was unclear if Republicans, who have a razor-thin Senate majority, could garner the 50 votes necessary for the measure to pass. The budget office’s findings added to this uncertainly.

Sen. Susan Collins (R-Maine), a moderate who has been on the fence about the bill, tweeted late this afternoon that she could not support the current bill based on the CBO score. “I want to work with my GOP and Democratic colleagues to fix the flaws in ACA. CBO analysis shows Senate bill won’t do it. I will vote no” on bringing the bill to the Senate floor, she announced.

Senate Democrats were also swift to react.

“The CBO report should be the end of the road for Trumpcare,” tweeted Senate Minority Leader Chuck Schumer (D-N.Y.). And, in a statement, Sen. Ron Wyden (D-Ore.) said it was “abundantly clear [Republicans] are going in the wrong direction.”

Sen. Bernie Sanders (I-Vt.) pointed to the analysis and said the GOP plan was “a cynical and immoral proposal.”

Detailing The Medicaid Numbers

Under the GOP measure, federal spending on Medicaid would drop by 26 percent over current spending projections, or $772 billion, over the next decade, according to the analysis.

The drop in spending would occur mainly because the Senate plan phases out federal funds for states to expand Medicaid and it puts annual caps on federal Medicaid dollars to states. Currently, federal Medicaid matching payments to states are open-ended.

By 2026, the budget office predicted, 15 million fewer people would be enrolled in Medicaid than projected under the ACA. Currently, more than low-income and disabled people are Medicaid beneficiaries.

How Medicaid beneficiaries are affected by these caps depends on how states respond to them, the CBO notes.

“With less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to finance the program at current-law levels or to reduce spending by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes,” according to the analysis.

The Medicaid funding provisions are a key reason several influential health groups say they cannot support the bill.

“Access to care for some of the most vulnerable members of our society — including those who require treatment for opioid-use disorder — would be endangered by the Senate proposal’s arbitrary, unsustainable, and shortsighted formula for funding Medicaid,” David Barbe, president of the American Medical Association, said in a statement posted on the organization’s website.

And even before the CBO report was issued, the National Association of Medicaid Directors was on record with its concerns. “The Senate bill does formalize several critical administrative and regulatory improvements, such as giving Medicaid Directors a seat at the table in the development of regulations that impact how the program is run, and the pathway to permanency for certain waiver programs,” the group said. “However, no amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill.”

Other organizations, such as Families USA and the American Public Health Association, said the CBO’s findings show the Senate proposal did “devastating harm” and would “seriously jeopardize the health of America.”

Cost And Coverage

The budget scorekeepers also concluded that, for the individual insurance market, premium costs would go down under the Senate plan, but so would the amount of coverage provided.

Because these plans “would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law,” CBO said.

In 2017, an estimated people bought health coverage through the ACA’s marketplaces. Most bought silver-level plans, which covered 70 percent of health care costs.

Under the Senate’s plan, the average premiums for an individual in 2020 would be about 30 percent lower. But these policies would cover about 58 percent of costs on average.

According to the CBO, “a combination of factors would lead to that decrease – most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.”

The CBO also analyzed the Senate bill provision that would allow states to use waivers to modify the health law’s that include items like prescription drugs, maternity coverage, mental health and substance abuse. In states where such waivers were granted, consumers could experience substantial cost increases for supplemental premiums or out-of-pocket spending, or choose to forgo services. Nearly half the population, the CBO estimates, would reside in states that seek these waivers.

In addition, the ACA’s ban on lifetime and annual limits on covered benefits would no longer apply to health benefits not defined as essential in a state.

Note: This story was updated to correct the party affiliation of Sen. Ron Wyden. He is a Democrat.Ìý

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House Speaker Paul Ryan pulled the bill from consideration after he rushed to the White House to tell President Donald Trump that there weren’t the 216 votes necessary for passage.

“We came really close today, but we came up short,” he told reporters at a hastily called news conference.

When pressed about what happens to the federal health law, he added, “Obamacare is the law of the land. … We’re going to be living with Obamacare for the foreseeable future.”

Trump laid the blame at the feet of Democrats, complaining that not one was willing to help Republicans on the measure, and he warned again that the Obamacare insurance markets are in serious danger. “Bad things are going to happen to Obamacare,” he told reporters at the White House. “There’s not much you can do to help it. I’ve been saying that for a year and a half. I said, look, eventually it’s not sustainable. The insurance companies are leaving.”

But he said the collapse of the bill might allow Republicans and Democrats to work on a replacement. “I honestly believe the Democrats will come to us and say, ‘Look, let’s get together and get a great health care bill or plan that’s really great for the people of our country,'” he said.

Ryan originally had hoped to hold a floor vote on the measure Thursday — timed to coincide with the seventh anniversary of the ACA — but decided to delay that effort because GOP leaders didn’t have enough “yes” votes. The House was in session Friday before his announcement while members debated the bill.

House Democratic leader Nancy Pelosi (Calif.) said the speaker’s decision to pull the bill “is pretty exciting for us …Ìýa victory for the Affordable Care Act, more importantly for the American people.”

The legislation was damaged by a variety of issues raised by competing factions of the party. Many members were nervous about reports by the showing that the bill would lead eventually to 24 million people losing insurance, while some moderate Republicans worried that would hurt low-income Americans.

At the same time, conservatives, especially the hard-right House Freedom Caucus that often has needled party leaders, complained that the bill kept too much of the ACA structure in place. They wanted a straight repeal of Obamacare, but party leaders said that couldn’t pass the Senate, where Republicans don’t have enough votes to stop a filibuster. They were hoping to use a complicated legislative strategy calledÌýÌýthat would allow them to repeal only parts of the ACA that affect federal spending.

The decision came after a chaotic week of negotiations, as party leaders sought to woo more conservatives. Trump personally lobbied 120 members through personal meetings or phone calls, according to a count provided Friday by his spokesman, Sean Spicer. “The president and the team here have left everything on the field,” Spicer said.

On Thursday evening, Trump dispatched Office of Management and Budget Director Mick MulvaneyÌýto tell his former House GOP colleagues that the president .ÌýIt was time to move on to other priorities, including tax reform, he told House Republicans.

“He said the president needs this, the president has said he wants a vote tomorrow, up or down. If for any reason it goes down, we’re just going to move forward with additional parts of his agenda. This is our moment in time,” Rep. Chris Collins (R-N.Y.), a loyal Trump ally, told reporters late Thursday. “If it doesn’t pass, we’re moving beyond health care. … We are done negotiating.”

Trump’s edict clearly irked some lawmakers, including the (R-N.C), whose group of more than two dozen members represented the strongest bloc against the measure.

“Anytime you don’t have 216 votes, negotiations are not totally over,” he told reporters who had surrounded him in a Capitol basement hallway as he headed in to the party’s caucus meeting.

Trump, Ryan and other GOP lawmakers tweaked their initial package in a variety of ways to win over both conservatives and moderates.ÌýBut every time one change was made to win votes in one camp, it repelled support in another.

The White House on Thursday accepted conservatives’ demands that the legislation strip federal guarantees of in insurance policies. But that was another problem for moderates, and Democrats suggested the provision would not survive in the Senate.

Republican moderates in the House — as well as the Senate — objected to the bill’s provisions that would to a set amount of funding for states that would also give governors and state lawmakers more flexibility over the program. Moderates also were concerned that the package’s tax credits would not be generous enough to help older Americans — who could be than their younger counterparts — afford coverage.

The House package also lost the support of key GOP allies, including the Club for Growth and Heritage Action. , patient and also opposed it.

But Ryan’s comments made clear how difficult this decision was. “This is a disappointing day for us,” he said. “Doing big things is hard. All of us. All of usÌý— myself included — we will need time to reflect on how we got to this moment, what we could have done to do it better.”

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The legislation would keep the health law’s provisions allowing adult children to stay on their parents’ health insurance plan until age 26 and prohibiting insurers from charging people with preexisting medical conditions more for coverage as long as they don’t let their insurance lapse.Ìý If they do, insurers can charge a flat 30 percent late-enrollment surcharge on top of the base premium, under the Republican bill.

In a statement, House Speaker Paul Ryan (R-Wis.) said the proposal would “drive down costs, encourage competition, and give every American access to quality, affordable health insurance. It protects young adults, patients with preexisting conditions, and provides a stable transition so that no one has the rug pulled out from under them.”

The GOP plan, as predicted, and would not enforce the so-called employer mandate, which requires certain employers to provide a set level of health coverage to workers or pay a penalty.

Democrats quickly condemned the bill. “Tonight, Republicans revealed a Make America Sick Again bill that hands billionaires a massive new tax break while shifting huge costs and burdens onto working families across American,” House Minority Leader Nancy Pelosi tweeted. “Republicans will force tens of millions of families to pay more for worse coverage — and push millions of Americans off of health coverage entirely.”

The legislation has been the focus of intense negotiations among different factions of the Republican Party and the Trump administration since January. The Affordable Care Act passed in 2010 without a single Republican vote, and the party has strongly denounced it ever since, with the House voting more than 60 times to repeal Obamacare. But more than 20 million people have gained coverage under the law, and President Donald Trump and some congressional Republicans have said they don’t want anyone to lose their insurance.

When Republicans took control of both Congress and the White House this year, they did not have an agreement on the path for replacement, with some lawmakers from states that have expanded Medicaid concerned about the effect of repeal and the party’s conservative wing pushing hard to jettison the entire law.

Sen. Rand Paul (R-Ky.), one of those favoring a full repeal, tweeted: “Still have not seen an official version of the House Obamacare replacement bill, but from media reports this sure looks like Obamacare Lite!”

Complicating the effort is the fact that Republicans have only 52 seats in the Senate, so they cannot muster the 60 necessary to overcome a Democratic filibuster. That means they must use a complicated legislative strategy called that allows them to repeal only parts of the ACA that affect federal spending.

Beginning in 2020, the GOP plan would provide tax credits to help people pay for health insurance based on household income and age, with a limit of $14,000 per family.ÌýEach member of the family would accumulate credits, ranging from $2,000 for an individual under 30 to $4,000 for people age 60 and older.ÌýThe credits would begin to diminish after individuals reached an income of $75,000 — or $150,000 for joint filers.

Consumers also would be allowed to put more money into tax-free health savings accounts and would lift the $2,500 cap on flexible savings accounts beginning in 2018.

The legislation would allow insurers to charge older consumers than younger people. The health law currently permits a 3-to-1 ratio.

Community health centers would receive $422 million in additional funding in 2017 under the legislation, which also places a and prohibits the use of tax credits to purchase health insurance that covers abortion.

Both the Energy and Commerce and Ways and Means Committees are scheduled to mark up the legislation Wednesday. The committees do not yet have any Congressional Budget Office analysis of how much the legislation would cost or how many people it would cover.

Party leaders have said they want to have the bill to President Trump next month.

In a statement, senior Democrats on both panels said the measure would charge consumers “more money for less care. It would dramatically drive up health care costs for seniors. And repeal would ration care for more than 70 million Americans, including seniors in nursing homes, pregnant women and children living with disabilities by arbitrarily cutting and capping Medicaid,”Ìýsaid Rep. Frank Pallone of New Jersey and Rep. Richard Neal of Massachusetts.

The House GOP plan makes dramatic changes to Medicaid, the state-federal health insurance program that covers 70 million low-income Americans. The program began in 1965 as an entitlement — which means federal and state funding is ensured regardless of cost and enrollment. But the Republican bill would cap federal funding for Medicaid for the first time.

The federal government picks up between half and 70 percent of Medicaid costs. The percentage varies based on the relative wealth of the state.

Under the GOP plan, federal funding would be based on what the government spent in the fiscal year that ended Sept. 30. Those amounts would be adjusted annually based on a state’s enrollment and medical inflation.

Currently, federal payments to states also take into account how generous the state’s benefits are and what rate it uses to pay providers. That means states like New York and Vermont get higher funding than states like Nevada and New Hampshire and those differences would be locked in for future years.

Republicans have pushed to cap federal funding to states in return for giving them more control in running the program.

The legislation also affects the health law’s expansion of Medicaid, in which the federal government provided enhanced funding to states to widen eligibility. The bill would also end that extra funding for anyone enrolling under the expansion guidelines starting in 2020. But the legislation would let states keep the extra funding Obamacare provided for individuals already in the expansion program who stay enrolled.

About 11 million Americans have gained Medicaid coverage since 2014.

Changing the expansion program is a delicate balance for the Republicans. Four GOP senators from states that took that option said Monday they would oppose any legislation that repealed the expansion.

“We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services,” Sens. Rob Portman of Ohio, Shelley Moore CapitoÌýof West Virginia, Cory GardnerÌýof Colorado andÌýLisa MurkowskiÌýof Alaska wrote to Majority Leader Mitch McConnell.

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The Affordable Care Act of course affected premiums and insurance purchasing. It guaranteed people with pre-existing conditions could buy health coverage and allowed children to stay on parents’ plans until age 26. But the roughly 2,000-page bill also included a host of other provisions that affect the health-related choices of nearly every American.

Some of these measures are evident every day. Some enjoy broad support, even though people often don’t always realize they spring from the statute.

In other words, the outcome of the repeal-and-replace debate could affect more than you might think, depending on exactly how the GOP congressional majority pursues its goal to do away with Obamacare.

No one knows how far the effort will reach, but here’s a sampling of sleeper provisions that could land on the cutting-room floor:

CALORIE COUNTS AT RESTAURANTS AND FAST FOOD CHAINS

Feeling hungry? The law tries to give you more information about what that burger or muffin will cost you in terms of calories, part of an effort to combat the ongoing obesity epidemic. Under the ACA, most restaurants and fast food chains with at least 20 stores must of their menu items. Several states, including New York, already had similar rules before the law. Although there was some pushback, the rule had industry support, possibly because posting calories was seen as less onerous than such things as taxes on sugary foods or beverages. The final rule went into effect in December after a one-year delay. One thing that is still unclear: Does simply seeing that a particular muffin has more than 400 calories cause consumers to choose carrot sticks instead?Ìý Results are mixed. One large meta-analysis done before the law went into effect didn’t show a significant reduction in calorie consumption, although the authors concluded that is “a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories.”

PRIVACY PLEASE: WORKPLACE REQUIREMENTS FOR BREAST-FEEDING ROOMS

Breast feeding, but going back to work? The law requires employers to provide women to express milk for up to a year after giving birth and provide someplace — other than a bathroom — to do so in private. In addition, most health plans breastfeeding support and equipment, such as pumps, without a patient co-payment.

LIMITS ON SURPRISE MEDICAL COSTS FROM HOSPITAL EMERGENCY ROOM VISITS

If you find yourself in an emergency room, short on cash, uninsured or not sure if your insurance covers costs at that hospital, the law provides some . If you are in a hospital that is not part of your insurer’s network, the Affordable Care Act requires all health plans to charge consumers the same co-payments or co-insurance for out-of-network emergency care as they do for hospitals within their networks. Still, the hospital could “balance bill” you for its costs —Ìýincluding ER care — that exceed what your insurer reimburses it.

If it’s a non-profit hospital — and about 78 percent of all hospitals are — the law requires it to post online a written , spelling out whether it offers free or discounted care and the eligibility requirements for such programs. While not prescribing any particular set of eligibility requirements, the law requires hospitals to charge lower rates to patients who are eligible for their financial assistance programs. That’s compared with their gross charges, also known as chargemaster rates.

NONPROFIT HOSPITALS’ COMMUNITY HEALTH ASSESSMENTS

The health law also requires non-profit hospitals to the billions of dollars in tax exemptions they receive by demonstrating how they go about trying to improve the health of the community around them.

Every three years, these hospitals have to perform a community needs assessment for the area the hospital serves. They also have to develop — and update annually — strategies to meet these needs. The hospitals then must provide documentation as part of their annual reporting to the Internal Revenue Service. Failure to comply could leave them liable for a $50,000 penalty.

A WOMAN’S RIGHT TO CHOOSE … HER OB/GYN

Most insurance plans must allow women to seek care from an obstetrician/gynecologist without having to get a referral from a primary care physician. While the majority of states already had such protections in place, those laws did not apply to self-insured plans, which are often offered by large employers. The health law to all new plans. Proponents say direct access makes it easier for women to seek not only reproductive health care, but also related screenings for such things as high blood pressure or cholesterol.

AND WHAT ABOUT THOSE THERAPY COVERAGE ASSURANCES FOR FAMILIES WHO HAVE KIDS WITH AUTISM?

Advocates for children with autism and people with degenerative diseases argued that many insurance plans did not provide care their families needed. That’s because insurers would cover rehabilitation to help people regain functions they had lost, such as walking again after a stroke, but not care needed to either gain functions patients never had, such speech therapy for a child who never learned how to talk, or to maintain a patient’s current level of function. The law requires plans to offer coverage for such treatments, dubbed , as part of the essential health benefits in plans sold to individuals and small groups.

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Department of Health and Human Services Secretary Sylvia Burwell Wednesday acknowledged that the Affordable Care Act’s fourth enrollment season, scheduled to begin Nov. 1 and run until Jan. 31, is a pivotal time for President Barack Obama’s signature domestic policy achievement.

“Building a new market is never easy,” she said in remarks at HHS headquarters, where she also unveiled ACA enrollment estimates for the upcoming year. “We expect this to be a transition period for the marketplace. Issuers are adjusting their prices, bringing them in line with actual data on costs.”ÌýBurwell’s comments foreshadowed the Ìýfor the next enrollment season. Federal officials are likely to release those numbers just days before the presidential election that could determine whether the ACA is repealed or revamped.

While the health law hasn’t been a predominant issue in the current election season, it has been at the center of a bitter battle between political parties since it was passed in 2010. The House of Representatives has voted to repeal all or part of the measure and the law has survived some court challenges and faces others.

Burwell noted those fights when talking about issues that have arisen in the implementation of the law that need to be resolved and said that “it also hasn’t helped that at nearly every turn, we’ve had to overcome partisan attempts to repeal and undermine the law through legislation and litigation.”

Enrollment in the state and federal marketplaces is expected to grow by about a million people next year —Ìýfrom about 12.7 million to 13.8 million, according to released Wednesday. The number of consumers who actually pay premiums and stay in the market is expected to average about 10.5 million per month this year and about in 2017.

Consumers flow in and out of ACA plans because they change jobs, get coverage from other sources and face other factors that affect where and how they enroll in health insurance, including affordability. About 9.2 million of the 13.8 million who now have ACA coverage are expected to reenroll, according to HHS.

This year’s enrollment period is focused on signing up healthier consumers —Ìýincluding the “young invincibles” between the ages of 18 and 34 who tend to have fewer ailments —Ìýand making the enrollment process faster and simpler. They will also remind consumers of the penalty for not having coverage, which . The flat penalty will be adjusted for inflation in 2017.

Federal officials are also focusing enrollment efforts on the 5.1 million Americans who are eligible to purchase health care coverage on the exchanges but do so elsewhere, according to HHS figures.ÌýOf that group, 2.5 million people could be eligible for the law’s financial assistance if they sign up for coverage during open enrollment, . A from the Kaiser Family Foundation found that 11.7 million people who remain without health insurance are eligible for Medicaid in their state or for tax credits to purchase health insurance through their state’s ACA marketplace. (KHN is an editorially independent program of the Kaiser Family Foundation.)

The outcome of the November elections may well determine the future of the ACA as much as the willingness of insurers to offer coverage and consumers to enroll in the plans. Republican presidential nominee Donald Trump has promised to the law, while Democratic nominee Hillary Clinton has said she wants to , making it more affordable for consumers who don’t qualify for subsidies and struggle to afford coverage.

Burwell called on Congress to work with her and the Obama administration to make needed changes to the law. “To make more substantial changes, like a public option to encourage competition, we’ll need cooperation from Congress,” she said. “And we are hopeful that soon, we’ll see more bipartisan efforts to make improvement.”

Bipartisan cooperation most likely won’t happen until the next Congress, if then. Much will depend on who is in power, whether GOP leaders think the ACA is still a potent political issue and how willing Democrats will be to make changes that might appeal to Republicans.

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Even as the cost of EpiPens dramatically rose, so too did the number of prescriptions written for patients in Medicare, sending spending by the program skyrocketing nearly 1,100 percent from 2007 to 2014, a shows.

During the same period, the total number of Medicare beneficiaries using EpiPens climbed 164 percent, from nearly 80,000 users in 2007 to more than 211,000 in 2014, according to the analysis by the Kaiser Family Foundation. While the report does not delve into what’s behind the increase, factors could include increased awareness among people with allergies, marketing efforts and access to insurance coverage.

The abrupt rise is notable because many people think that life-threatening allergies are less common among the elderly. In addition, epinephrine —Ìýthe active ingredient in EpiPens —Ìýcan pose greater risks to older adults. Food and Drug Administration urges caution when prescribing to this age group.

“That level of increase gives me pause,” said Martha Twaddle, senior medical officer for Illinois at Aspire Health, which provides home-based supportive care for people with serious illness.Ìý She did not work on the study. Epinephrine —Ìýthe active ingredient in EpiPens —Ìýcan cause side effects including chest pain, rapid increase in blood pressure or irregular heart rhythms, which could be fatal, for people with certain medical conditions, including heart disease.

The foundation study comes amid ongoing scrutiny —Ìýincluding Wednesday by Mylan CEO Heather Bresch —Ìýover EpiPen price increases. (Kaiser Health News is an editorially independent program of the Foundation.)

EpiPens are used in cases of severe allergic reactions.ÌýCosts for a two-pack of the pens has gone from about $94 in January 2007 to $609 in May of this year.ÌýIn response to criticism of its price increase, Mylan announced in late August that it would make a and price it at half of its current brand name price.

The new numbers from Medicare could add fuel to the debate over these price increases and voters’ demands that Congress take action to roll back the cost of the popular medication.

The health insurance program for senior citizens and disabled people spent about $6.4 million on the devices in 2007, but spent $75.3 million in 2014, with sharp price hikes by the manufacturer driving much of the increase. Those figures reduce the amount spent based on estimates of how much Medicare saved in rebates from manufacturers, although the agency would not disclose the exact amounts.

Still, when patients show up in emergency rooms with life-threatening allergic reactions, epinephrine is a first line of defense, said Robert Glatter, emergency room physician at Lenox Hill Hospital in Manhattan. Those whose allergic reaction isn’t immediately life threatening would more likely get a mix of steroids and antihistamines, he said.

All patients with suspected severe allergic reactions —Ìýeven the elderly —Ìýare given either a prescription or an actual epinephrine auto injector upon discharge, he said.

“We tell them to have it and use it if they have a lip or tongue swelling, shortness of breath, a skin rash [or other symptoms] of a problem,” said Glatter, adding that adults tend to become more susceptible to food allergies as they age.

Increased awareness among doctors and patients about the importance of epinephrine could account for some of the increase seen in the study, said Richard Lockey, a past president of both the World Allergy Organization and the American Academy of Allergy, Asthma & Immunology.

“Most people survive an allergic reaction … the people who don’t survive are those who don’t get epinephrine or don’t get it soon enough,” said Lockey, who says it is necessary to balance this idea with the possible risks epinephrine poses for older patients. “It’s a matter of clinical judgment.”

Although Medicare is generally thought of as the government health program for older people, about 16 percent —Ìýor 9.1 million beneficiaries —Ìýare younger than 65. They are generally disabled or have kidney problems requiring dialysis. According to foundation researchers, although the majority of users were older than 65, a disproportionate share – 35 percent — of the EpiPen users were younger than 65. Additionally, 26 percent were between 65 and 69. Use fell off with age, with only 15 percent of the users being between ages 75-85.

“You can come up with a ton of reasons why the under-65 population might see an increase in EpiPen use,” said James Goodwin, an expert in geriatric medicine at the University of Texas Medical Branch in Galveston. He did not work on the study.

As for the overall increase, Goodwin said there are likely many factors and it isn’t necessarily evidence of overutilization. Still, Goodwin says he specializes in patients older than age 80 and has never prescribed an EpiPen, nor had three of his colleagues, who work with slightly younger elderly patients.

One geriatrician said he has patients who are on it with prescriptions from their allergists, who weigh the pros and cons of having the drug. Those physicians “are the ones to say your allergy is serious enough to potentially become life threatening.”

At the American Geriatrics Society, epinephrine is not included on the , said Nicole Brandt, a professor at the School of Pharmacy at the University of Maryland.

“When you look at in context of someone having a severe anaphylactic reaction, which is life threatening, you want access to treatment,” said Brandt. She said doctors should caution patients about the appropriate use of the devices and encourage them to seek additional medical attention if they experience side effects.

She suggested the increase in Medicare prescriptions seen in the study reflects access to insurance more than overuse.

Since Medicare drug plans cover part of enrollees’ total drug costs, beneficiaries in prescription drug plans pay less that the full retail price. But beneficiaries still paid significantly more of their own money for EpiPens during the seven-year period studied in the report. Average out-of-pocket spending for beneficiaries with Medicare drug coverage nearly doubled for each EpiPen, from $30 to $56. The report does not include price increases beyond 2014.

Still, those costs are far less than what some people with private insurance might pay, particularly those with high deductibles. As a result, at least one doctor —Ìýgeriatrician David Barile from Princeton, New JerseyÌý—Ìýwho did not work on the study, speculated that the rise in Medicare use of EpiPens might simply be older people getting them for their grandchildren.

Liz Szabo contributed to this report.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the .

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In addition, HHS is focusing on outreach efforts to get those still uninsured —Ìýespecially younger and healthier individuals —Ìýto enroll when the marketplaces open on Nov. 1, she told reporters during a briefing at HHS.Ìý Potential enrollees under 34 are “driven by deadlines” and often enroll closer to the end of the open enrollment period, Burwell said.

Three of the nation’s largest health insurers — Aetna, UnitedHealthcare and Humana — have announced they will sell individual plans in 2017. So, too, will several Blue Cross and Blue Shield plans in various states. That’s on top of the 16 nonprofit since January 2015.

The announcements, however, apply generally only to the individual market. The much larger market of employer-sponsored insurance is not part of the health law exchanges.

While some consumers will and for coverage, 85 percent of exchange enrollees received tax credits to help offset the rise in premiums, Burwell said.Ìý She said she continues to talk with insurers and state insurance commissioners to encourage greater participation in the marketplaces.

HHS also recently proposed to reflect insurers’ concerns, such as how to better account for individuals who aren’t enrolled in a health plan for an entire year, starting in 2017. ÌýOther steps include better use of drug utilization data and how to spread the risk of high-cost enrollees in 2018.

Burwell also mentioned HHS is seeking to increase enrollment by working with the Internal Revenue Service to contact people who paid a penalty for not having coverage and providing information about how to enroll on the exchanges. HHS and other federal agencies have also worked to reduce “data matching” errors that may have prevented eligible people from signing up for coverage.

Meanwhile, Burwell urged lawmakers returning to Capitol Hill next week to move quickly on a bipartisan basis to pass new funding to fight the .Ìý “This is an emergency … this is a national issue,” Burwell said.

Earlier this week, the director of the federal Centers for Disease Control and Prevention, Dr. Tom Frieden, warned that federal funds to fight the Zika virus .

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