Following the Trail of the Affordable Care Act Debate: Part 10

By Zach Cahill and David White

Republican efforts to repeal the Affordable Care Act (ACA) broke onto the scene again this Wednesday May 24th. The rollercoaster of news and rumors around those efforts once again bring uncertainty to the lives of patients, physicians, and insurers nationwide. 

All news is not good news

In our last installment, we detailed the seemingly unlikely passage of the American Health Care Act (AHCA) – the House Republican bill to repeal and replace the ACA. Contrary to Speaker Paul Ryan’s own preferred procedure in the House, AHCA was passed without a new score from the Congressional Budget Office (CBO), which was needed to account for changes made to the bill since the previous CBO score was published. You can read about the last score in Part 6 of our series.

Now, weeks after the narrow vote in the House to pass the AHCA, the CBO released a final score of the bill with similar outcomes to the previous. Coverage estimates are still bleak. Twenty- three million Americans are projected to lose coverage by 2026. This will bring the estimated number of uninsured to 51 million in a decade. These increases will disproportionately impact older and poorer individuals.

The changes to access and affordability of insurance in the individual market bore the brunt of the CBO’s analysis. Two amendments added right before the AHCA passed allowed states to apply for waivers from two key ACA provisions: Essential Health Benefits and Community Ratings. Opting out of either of these will have significant impact on the insurance market in the applying state. In fact, the CBO estimated that one in three Americans live in states that may apply for waivers. Uncertainty surrounding implementing waivers and their impact on insurance policies lead the CBO to project that receiving a waiver would destabilize the individual insurance market for one in six Americans. 

AHCA attempts to dampen that impact by establishing a Patient and State Stability Fund with an extra $8 billion for states that opt for waivers. While the amount would be large enough to attract applicants, the CBO estimated that it was not large enough to lower premiums. Prospects for older and poorer people in the individual market are still bleak. The average 64-year-old earning just above the poverty line would have to pay about 9 times more in premiums than under current law, potentially over 60% of their annual income.

It is now officially a problem for the Senate

What the Senate’s version of healthcare reform will look like is still unclear. The poor CBO score on the House version makes it more likely that they will produce a very different bill. The $119 billion deficit reduction number in the CBO score means that the bill does meet certain parliamentary requirements under the budget reconciliation rules and makes for an attractive deficit target. The Senate will forge its own path to achieve that deficit reduction and make their own coverage calculations.  With only two votes to lose and a variety of competing factions, the road to the president’s desk is narrow, but passable.

Two more hurdles remain for the legislative prong of the Republican repeal and replace plan. A successful Senate bill will go to a conference committee of the House and Senate where a compromise will have to be reached – followed by separate votes in both chambers before it could go to the White House.

A step back

During the chaos of the early days of the new Congress, and especially after the failure of the first version of the AHCA in April, it seemed possible that action to dismantle the ACA legislatively would not happen. The past month has told a different story. We have seen that the Republican leadership in Congress’s primary goal is doing something, regardless of what it is. It is more likely now that we will now see a bill branded “Repeal and Replace” land on the President’s desk this year – although we have seen this pendulum swing before. 

First, repealing Medicaid expansion is likely to hurt kidney patients. A limited study from the journal Health Affairs stated that:

“Changes in disease prevalence between 2013 and 2016 by state were nonsignificant for all but kidney disease, which showed a small decline in expansion states (-2.2 percentage points, p=0.06)”. 

Access to care is critical for these vulnerable populations who often suffer from multiple comorbidities. Second, removing protections for preexisting conditions could make being a kidney donor a risk factor when applying for health insurance. Many obstacles already exist for potential living organ donors, health insurance penalties should not be one of them. Third, in some states, immunosuppressants are covered as Essential Health Benefits. Medicare covers these patients three years after transplant, but after that they are on their own.  Essential Health Benefits offer protection and peace of mind for those patients. 

ASN will continue to monitor this bill as it moves through the Senate.

Following the Trail of the Affordable Care Act Debate: Part 1Part 2Part 3Part 4Part 5Part 6Part 7Part 8, Part 9

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Republican efforts to repeal the Affordable Care Act (ACA) broke onto the scene again this Wednesday May 24th. The rollercoaster of news and rumors around those efforts once again bring uncertainty to the lives of patients, physicians, and insurers nationwide. 

All news is not good news

In our last installment, we detailed the seemingly unlikely passage of the American Health Care Act (AHCA) – the House Republican bill to repeal and replace the ACA. Contrary to Speaker Paul Ryan’s own preferred procedure in the House, AHCA was passed without a new score from the Congressional Budget Office (CBO), which was needed to account for changes made to the bill since the previous CBO score was published. You can read about the last score in Part 6 of our series.

Now, weeks after the narrow vote in the House to pass the AHCA, the CBO released a final score of the bill with similar outcomes to the previous. Coverage estimates are still bleak. Twenty- three million Americans are projected to lose coverage by 2026. This will bring the estimated number of uninsured to 51 million in a decade. These increases will disproportionately impact older and poorer individuals.

The changes to access and affordability of insurance in the individual market bore the brunt of the CBO’s analysis. Two amendments added right before the AHCA passed allowed states to apply for waivers from two key ACA provisions: Essential Health Benefits and Community Ratings. Opting out of either of these will have significant impact on the insurance market in the applying state. In fact, the CBO estimated that one in three Americans live in states that may apply for waivers. Uncertainty surrounding implementing waivers and their impact on insurance policies lead the CBO to project that receiving a waiver would destabilize the individual insurance market for one in six Americans. 

AHCA attempts to dampen that impact by establishing a Patient and State Stability Fund with an extra $8 billion for states that opt for waivers. While the amount would be large enough to attract applicants, the CBO estimated that it was not large enough to lower premiums. Prospects for older and poorer people in the individual market are still bleak. The average 64-year-old earning just above the poverty line would have to pay about 9 times more in premiums than under current law, potentially over 60% of their annual income.

It is now officially a problem for the Senate

What the Senate’s version of healthcare reform will look like is still unclear. The poor CBO score on the House version makes it more likely that they will produce a very different bill. The $119 billion deficit reduction number in the CBO score means that the bill does meet certain parliamentary requirements under the budget reconciliation rules and makes for an attractive deficit target. The Senate will forge its own path to achieve that deficit reduction and make their own coverage calculations.  With only two votes to lose and a variety of competing factions, the road to the president’s desk is narrow, but passable.

Two more hurdles remain for the legislative prong of the Republican repeal and replace plan. A successful Senate bill will go to a conference committee of the House and Senate where a compromise will have to be reached – followed by separate votes in both chambers before it could go to the White House.

A step back

During the chaos of the early days of the new Congress, and especially after the failure of the first version of the AHCA in April, it seemed possible that action to dismantle the ACA legislatively would not happen. The past month has told a different story. We have seen that the Republican leadership in Congress’s primary goal is doing something, regardless of what it is. It is more likely now that we will now see a bill branded “Repeal and Replace” land on the President’s desk this year – although we have seen this pendulum swing before. 

First, repealing Medicaid expansion is likely to hurt kidney patients. A limited study from the journal Health Affairs stated that:

“Changes in disease prevalence between 2013 and 2016 by state were nonsignificant for all but kidney disease, which showed a small decline in expansion states (-2.2 percentage points, p=0.06)”. 

Access to care is critical for these vulnerable populations who often suffer from multiple comorbidities. Second, removing protections for preexisting conditions could make being a kidney donor a risk factor when applying for health insurance. Many obstacles already exist for potential living organ donors, health insurance penalties should not be one of them. Third, in some states, immunosuppressants are covered as Essential Health Benefits. Medicare covers these patients three years after transplant, but after that they are on their own.  Essential Health Benefits offer protection and peace of mind for those patients. 

ASN will continue to monitor this bill as it moves through the Senate.

Following the Trail of the Affordable Care Act Debate: Part 1Part 2Part 3Part 4Part 5Part 6Part 7Part 8, Part 9

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