By a slim, 217-213 majority, the Republican controlled House of Representatives today passed the American Health Care Act, or AHCA. This is the same bill that failed to get a vote at the end of March, albeit with some minor tweaks. Many must be asking, what happens now? Is the bill law? How will everyone be impacted? I'll do my best to answer those questions below.
The AHCA in it's original form attempted to do four things:
- Repeal the Affordable Care Act's individual mandate,
- Scale back Medicaid expansion,
- Reduce and in some cases eliminate subsidies available to participants of the various state health exchanges,
- Eliminate certain taxes in the ACA which helped subsidies the marketplace.
The bill in it's original form did not receive a vote because a block of ultra-conservatives in the House, also known as the House Freedom Caucus (HFC), withheld their support because they felt the bill did not go far enough. The HFC wanted further provisions in the bill which would, among other things, allow insurers to charge more for people with pre-existing conditions and eliminate the requirement that all insurance plans cover 10 essential health benefits, including maternity and mental health care. As a result of the lack of support from the HFC, the initial bill as written failed.
However, continued pressure from the Trump administration caused lawmakers to revisit the original bill. A compromise was brokered between the leader of the HFC, Mark Meadows of North Carolina, and Tom MacArthur of New Jersey. The deal centered on an amendment proposed by MacArthur which would allow states to seek a waiver from the Department of Health & Human Services for certain "essential health benefits". States would be subject to various requirements, one of which would be to setup high-risk pools for the sickest people.
Initially, moderates in the Republican conference balked at this amendment because they feared states would use the waiver to eliminate the requirement that insurers cover pre-existing conditions. After a few days of back and forth, including intervention by Trump and his top deputies, an additional amendment was added that provided $8 billion in funding over five years to state high risk pools. This amendment was enough to win over moderates who had initially opposed the bill, and subsequently, the bill passed in a floor vote today.
Where do we go from here? First, let's declare that the bill is not law and the Affordable Care Act aka Obamacare is still the law of the land. Now the legislation moves to the Senate, where there is a very unclear path for this particular bill. Numerous Republican senators from states such as Ohio, West Virginia, Pennsylvania and many others have expressed alarm at the Medicaid rollbacks, primarily because hundreds of thousands of people have obtained coverage in those states because of the Medicaid expansion (almost 700,00 in Ohio alone). It is highly unlikely the bill in the form that passed the House will see a vote in the Senate.
What's more likely, in my opinion, is that Senate republicans write a new bill which includes some of the provisions from the recently passed House bill. Some examples would include refundable tax credits for insurance and the repeal of taxes & the individual mandate. Whether any bill that passes the Senate can also pass the House is unclear, and it's important to remember that both chambers must agree on the same bill before the President can sign into law.
The impacts are unclear. The Congressional Budget Office did not have a chance to score the bill and estimate costs and number of people who would lose coverage. However, based on the score of the previous AHCA which failed in March, we know that 24 million people would potentially lose coverage through 2026 and premiums would rise above current ACA projections through 2020, until they began to fall. A new score should be available in the coming weeks.
There is still a long road ahead, but certainly proponents of repeal are thrilled at the fact the AHCA made it out of the House. Celebrations took place in the Rose garden of the White House after the vote, with much backslapping, high-fiving and loud praises among the G.O.P conference for passing the bill. This may be premature, but for a conference that seemed to not be able to agree on anything, it certainly was a moment to savor.
I will continue to post over the coming months to keep you informed, and as always you can reach out to us at GreenpointMed with any questions.
**I do my best to present the facts and provide views on what is likely to happen in the legislative process. In most cases, I will attempt to limit my opinions regarding how I actually feel about the bill. For deeper analysis, please visit www.kkf.org, the Kaiser Family Foundation, which is world-class in their analysis of healthcare.**