Following the Trail of the Affordable Care Act Debate: Part 9

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By Zach Cahill and David White

When we last wrote about efforts to repeal the Affordable Care Act (ACA) on April 3rd, House Republicans pulled their bill, the American Health Care Act (AHCA), from the floor without a vote.  We wrote “The Affordable Care Act (ACA) is here to stay, for now.”  That remains true even after the vote Thursday, May 4, in which a new version of the AHCA passed the House of Representatives by a vote of 217-213, one vote over the 216-majority threshold.  However, this bill’s future in the Senate is far from clear.  

Let’s recap a very important fact about the current repeal effort.  This bill has been created under budget “reconciliation” instructions – a procedure that has only been used successfully in Congress 20 times since 1980.  The reason for using this process is that under Senate rules, legislation considered as a part of the "reconciliation" process cannot be filibustered and needs only a simple majority (51 votes) to pass.

According to an estimate of the original bill by the Congressional Budget Office (CBO) issued in March, the AHCA could result in 24 million more people uninsured by 2026.  The CBO did not have time to update that forecast for the revised AHCA before this vote.  However, Senate rules require the CBO to issue an updated estimate since the bill has been amended before it can be considered by the Senate under the rules that govern reconciliation.

Amendments to the AHCA

So, what changed over the past month to push this bill over the finish line?  We will discuss a few changes that were added in the past week to garner more Republican support.  For details on the rest of the AHCA, check out Part 8 of our series.

Protections for pre-existing conditions, that previously enjoyed bipartisan support, came under fire in this bill.  Under the ACA, insurers are prohibited from denying coverage to individuals based on preexisting medical conditions, such as cancer, high blood pressure or diabetes.  Furthermore, the ACA requires insurers to offer “community ratings” preventing insurers from charging those with costly medical conditions more than they charge other consumers in the general insurance pool.

However, an amendment by Representative Tom MacArthur (R-NJ) would allow states to obtain a waiver from the Health and Human Services Department so they could charge customers with preexisting conditions more than other people.  If HHS does not respond to a state’s waiver request within 60 days, the requested change would automatically go into effect.  A range of health experts predict that this amendment could result in a sharp rise in premium increases for those with medical problems. 

In response to the MacArthur amendment, Representatives Fred Upton (R-MI) and Billy Long (R-MO) negotiated a provision to add $8 billion to the $115 billion Patient and State Stability Fund.  This fund provides seven options for states to defray the cost of insurance for their residents, including “high risk” pools.  However, the legislation does not mandate how much money must be spent on each of the seven options, leaving open the possibility that the “high risk” pools will be underfunded.   In order to receive a waiver, a state must include the creation of a "risk-sharing plan" by either recreating so-called high-risk pools that existed before the ACA or designing a subsidy program for residents with preexisting conditions.

Finally, how does this bill affect “essential health benefits”?  This bill would change ACA provisions and allow states to preserve the current essential health benefits or create their own set of coverage requirements — or no requirements at all. 

Senate Reaction

There was a noticeable lack of enthusiasm in Senate on Thursday – even among GOP members.  Senate Health, Education, Labor, and Pensions Committee chairman Lamar Alexander (R-TN) released the following statement on House passage of the AHCA.

"I congratulate the House on passage of its bill. The Senate will now finish work on our bill, but will take the time to get it right. My own goals for a Senate bill include: 1) rescuing the thousands of Tennesseans and millions of Americans who will be trapped in collapsing  Affordable Care Act exchanges with few or even zero options for health insurance in 2018 unless Congress acts; 2) lowering premium costs, which have increased under the ACA law; 3) gradually giving states more flexibility on the Medicaid program, but doing this in a way that does not pull the rug out from under people who rely on Medicaid; and 4) making sure those with pre-existing conditions have access to insurance.”

While the bill that passed the House yesterday has many concerning provisions and unanswered questions, it is important to remember how a bill becomes law. ACA repeal must survive at least two more votes before going to the president’s desk. It is highly unlikely that the version we saw yesterday will emerge as the final bill. We will keep you updated as this effort moves to the Senate where a much slower and deliberative process is expected.

Following the Trail of the Affordable Care Act Debate: Part 1Part 2Part 3Part 4Part 5Part 6Part 7, Part 8

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When we last wrote about efforts to repeal the Affordable Care Act (ACA) on April 3rd, House Republicans pulled their bill, the American Health Care Act (AHCA), from the floor without a vote.  We wrote “The Affordable Care Act (ACA) is here to stay, for now.”  That remains true even after the vote Thursday, May 4, in which a new version of the AHCA passed the House of Representatives by a vote of 217-213, one vote over the 216-majority threshold.  However, this bill’s future in the Senate is far from clear.  

Let’s recap a very important fact about the current repeal effort.  This bill has been created under budget “reconciliation” instructions – a procedure that has only been used successfully in Congress 20 times since 1980.  The reason for using this process is that under Senate rules, legislation considered as a part of the "reconciliation" process cannot be filibustered and needs only a simple majority (51 votes) to pass.

According to an estimate of the original bill by the Congressional Budget Office (CBO) issued in March, the AHCA could result in 24 million more people uninsured by 2026.  The CBO did not have time to update that forecast for the revised AHCA before this vote.  However, Senate rules require the CBO to issue an updated estimate since the bill has been amended before it can be considered by the Senate under the rules that govern reconciliation.

Amendments to the AHCA

So, what changed over the past month to push this bill over the finish line?  We will discuss a few changes that were added in the past week to garner more Republican support.  For details on the rest of the AHCA, check out Part 8 of our series.

Protections for pre-existing conditions, that previously enjoyed bipartisan support, came under fire in this bill.  Under the ACA, insurers are prohibited from denying coverage to individuals based on preexisting medical conditions, such as cancer, high blood pressure or diabetes.  Furthermore, the ACA requires insurers to offer “community ratings” preventing insurers from charging those with costly medical conditions more than they charge other consumers in the general insurance pool.

However, an amendment by Representative Tom MacArthur (R-NJ) would allow states to obtain a waiver from the Health and Human Services Department so they could charge customers with preexisting conditions more than other people.  If HHS does not respond to a state’s waiver request within 60 days, the requested change would automatically go into effect.  A range of health experts predict that this amendment could result in a sharp rise in premium increases for those with medical problems. 

In response to the MacArthur amendment, Representatives Fred Upton (R-MI) and Billy Long (R-MO) negotiated a provision to add $8 billion to the $115 billion Patient and State Stability Fund.  This fund provides seven options for states to defray the cost of insurance for their residents, including “high risk” pools.  However, the legislation does not mandate how much money must be spent on each of the seven options, leaving open the possibility that the “high risk” pools will be underfunded.   In order to receive a waiver, a state must include the creation of a "risk-sharing plan" by either recreating so-called high-risk pools that existed before the ACA or designing a subsidy program for residents with preexisting conditions.

Finally, how does this bill affect “essential health benefits”?  This bill would change ACA provisions and allow states to preserve the current essential health benefits or create their own set of coverage requirements — or no requirements at all. 

Senate Reaction

There was a noticeable lack of enthusiasm in Senate on Thursday – even among GOP members.  Senate Health, Education, Labor, and Pensions Committee chairman Lamar Alexander (R-TN) released the following statement on House passage of the AHCA.

"I congratulate the House on passage of its bill. The Senate will now finish work on our bill, but will take the time to get it right. My own goals for a Senate bill include: 1) rescuing the thousands of Tennesseans and millions of Americans who will be trapped in collapsing  Affordable Care Act exchanges with few or even zero options for health insurance in 2018 unless Congress acts; 2) lowering premium costs, which have increased under the ACA law; 3) gradually giving states more flexibility on the Medicaid program, but doing this in a way that does not pull the rug out from under people who rely on Medicaid; and 4) making sure those with pre-existing conditions have access to insurance.”

While the bill that passed the House yesterday has many concerning provisions and unanswered questions, it is important to remember how a bill becomes law. ACA repeal must survive at least two more votes before going to the president’s desk. It is highly unlikely that the version we saw yesterday will emerge as the final bill. We will keep you updated as this effort moves to the Senate where a much slower and deliberative process is expected.

Following the Trail of the Affordable Care Act Debate: Part 1Part 2Part 3Part 4Part 5Part 6Part 7, Part 8

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