House Passes ACA Repeal Bill- Long Slog Awaiting in Senate

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    Whitfield L. Knapple, MD, FACG
    Chair, ACG National Affairs Committee

    The U.S. House of Representatives Thursday passed the American Health Care Act (AHCA), after months of negotiating with President Trump and fractions within the House Republican caucus.  The AHCA is designed to repeal and replace the Patient Protection and Affordable Care Act (“ACA”), which passed in 2010.  The House passed the bill on a 217-213 vote, with 20 Republicans and all Democrats voting “no.” Click here for the list of 20 Republicans who bucked party leadership and President Trump to vote “no.”

    ACG updated its membership last week on the agreement brokered by two leaders in the conservative and moderate Republican caucuses, the House Freedom Caucus and the Tuesday Group, respectively.  The amendment, sponsored by Tom MacArthur (R-NJ), creates a waiver system for states that want to opt out of the ACA’s essential benefits and community rating requirements. If enrollees did not maintain continuous coverage over the past year, insurers under the AHCA are allowed to increase premiums based on the enrollee’s health status for one year. States are required to set up subsidized high risk pools or reinsurance programs that help these enrollees afford coverage.  However, after moderate Republicans argued that the changes would weaken protections for individuals with pre-existing conditions, Republican leadership secured another amendment, sponsored by Fred Upton (R-MI).  To help reassure moderates concerned about the amount of funding provided by AHCA for these pools, Upton worked on an amendment to add $8 billion over five years to assist those with pre-existing conditions in states choosing to opt out of ACA requirements.

    The AHCA repeals the penalties associated with the individual and employer mandates retroactively to 2016. The bill also allows insurance companies to impose a 30% late-enrollment surcharge on individual or small group market beneficiaries who had a lapse in coverage for more than 63 days.  It also phases out the ACA’s Medicaid expansion, and transitions Medicaid to a “per capita cap model.”  Further, the bill eliminates a number of taxes in the ACA, including a delay of the “Cadillac Tax” on high cost health plans until 2026.  The full bill text was only unveiled hours before the vote. The Congressional Budget Office (CBO) didn’t have time to finish its study of the legislation.

    The CBO completed its initial analysis of the AHCA on March 13, 2017, and subsequently updated their analysis on March 23, 2017.  Therefore, the recent changes to appease groups within the House Republican party are obviously not accounted for in the CBO score.  The CBO analysis includes the combined analysis of the CBO and the staff of the Joint Committee on Taxation (JCT).  Overall, CBO and JCT estimate that the AHCA, as amended, would reduce federal deficits by $150 billion over the period of 2017-2026. CBO and JCT also estimate that in 2018, 14 million more people would be uninsured under the legislation than under current law. After additional changes to subsidies for insurance purchased in the non-group market and to the Medicaid program take effect, the increase in the number of uninsured people is expected to rise to 21 million in 2020, and then to 24 million in 2026.

    Next Stop: The U.S. Senate

    According to pundits, the ACA repeal fight is expected to get even tougher for Republicans in the U.S. Senate, who cannot afford more than two defections.  Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK) have spoken out against the bill’s ban on funding for Planned Parenthood.  Also, Republican Senators Shelly Moore Capito (R-WV), Cory Gardner (R-CO), Rob Portman (R-OH), and Lisa Murkowski jointly voiced their objections to the Medicaid cuts in the AHCA.  Health policy reporters say top Senate Republicans may effectively write their own bill from scratch, given the obstacles that the AHCA faces in the Senate.  It is unclear how any of these changes will impact getting a revised bill approved in the House.  Should these provisions be removed, the amended bill must go back to the U.S. House for approval, potentially forcing House Speaker Paul Ryan (R-WI), President Trump, and House Republicans to find agreement all over again.

    As the bill heads to the Senate, ACG is also monitoring items in the AHCA that are not considered to impact the federal government’s budget.  According to U.S. Senate budget rules, these issues must be removed from the bill in order to pass the bill by a simple majority. Key provisions vulnerable to removal may include the continuous coverage surcharge, changes to age-based rating, and these ACA-exemption waivers for states.  ACG remains part of these discussions and continues to advocate on behalf of clinical GI practitioners and patients.

    Whitfield L. Knapple, MD, FACG

    Chair, ACG National Affairs Committee

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