The Affordable Care Act replacement, the American Health Care Act, now heads to the Senate. Floor debate portrayed vastly different world views: one of a collapsing individual market where patients face rising out-of-pocket costs, and another in which those with serious chronic illnesses could return to the days of untouchable premiums.
House Republicans voted today to replace the Affordable Care Act (ACA), sending the Senate a bill that its proponents say will reduce premiums for most Americans and stabilize the healthcare market.
Opponents charge that the replacement plan, the American Health Care Act (AHCA), fails to meet a core test promised by President Donald J. Trump: a guarantee that those with preexisting conditions will be able to find affordable healthcare coverage.
The vote, 217-213, with 1 member not voting, came on party lines more than a month after Republican leaders in the House of Representatives abandoned a floor vote when they could not muster enough support. House leaders worked with members of the conservative Freedom Caucus, as well as a moderate, US Representative Tom MacArthur (R-New Jersey), to craft a compromise that conservatives felt would unravel enough ACA regulations and moderates felt would give states the option to retain key consumer protections. Twenty Republicans voted against the bill.
Floor debate portrayed 2 contrasting worldviews: one of a collapsing individual market where health insurers are fleeing and patients face rising out-of-pocket costs, and another in which patients with serious health conditions will lose access to coverage, and seniors now receiving Medicaid will face “dying alone,” in the words of US Representative Yvette Clark (D-New York).
Several Republican House members said the bill would bring down the cost of healthcare and increase choice. US Representative Neal Dunn (R-Florida), a physician, said, “We are giving (healthcare) back to the people. The American Health Care Act will lower the costs and serve the patients. This act eliminates the subsidies and mandates and defunds Planned Parenthood and puts Medicaid on a budget—and it is the largest entitlement reform in a generation.”
“You know what doesn’t cover preexisting conditions? A healthcare system that doesn’t have coverage!” said House Majority Leader Kevin McCarthy (R-California).
But US Representative Joseph Kennedy III (D-Massachusetts) said the AHCA represented “a worldview that scapegoats the struggling and the suffering, that sees fault in illness, that rejects the most basic universal truth of human experience, that every one of us will be brought to our knees diagnosis we didn’t expect, a phone call we can’t imagine and a loss we cannot endure. So, we take care of each other, because but for the grace of God, there one day go I.”
The highest-ranking leaders of both parties closed the debate. House Minority Leader Nancy Pelosi (D-California) the legislator perhaps most identified with the ACA from her tenure as House Speaker, read quotes from a host of religious organizations opposed to the replacement bill. “Speaker [Paul] Ryan once called this bill an act of mercy. There is no mercy here,” she said.
She portrayed the divide in moral terms, saying that moderate Republicans who supported the ACA repeal would have the vote “tattooed on your forehead.”
“As Pope Francis said, Health is not a consumer good, but a universal right. So, access to health services cannot be a privilege.”
House Speaker Ryan followed Pelosi, saying that “There is a fundamental urgent choice at the heart of this debate.” Staying with the ACA as is, he said, “means even higher premiums, even fewer choices, even more insurance companies pulling out, even more uncertainty, and even more chaos.”
“This is a crisis, and it is happening right now," he said.
Key elements of the bill include:
· States gain powers to seek waivers to the ACA’s requirement to cover 10 “essential health benefits,” which include mental health care and pregnancy.
· States can create high-risk pools to cover those with preexisting conditions, and a late change added more funding to subsidize these premiums.
· The core of the AHCA converts Medicaid to a system of block grants and scales back funding, which opponents say will allow the Trump administration and Congressional Republicans to fund tax cuts.
· The bill tilts costs away from younger adults toward those in their 50s and 60s, by allowing insurers to charge older adults 5 times what the youngest adults pay, instead of 3 times what young adults pay. The bill retains the popular provision of allowing young adults to stay on their parents’ health plans through age 26.
Since the ACA passed in 2010, an estimated 21 million Americans gained health coverage, but far fewer adults have enrolled in the individual marketplaces than projected. Insurers said that the exchanges were overloaded with too many very sick people and not enough young healthy adults. Insurers said ACA requirements made premiums for young adults too expensive, while penalties for not having coverage were too light. And, it was too easy for those with health needs to “game the system” by enrolling when they needed a treatment or surgery and drop out afterward, leaving insurers on the hook for their costs.
Rule changes from HHS will tighten up some of these problems—the 2018 open enrollment period will run just 6 weeks, from November 1, 2017, to December 15, 2017.
The Congressional Budget Office projected that the original version of the AHCA would cause 24 million Americans to lose health coverage by 2026, while reducing the deficit by $337 billion. The revised version of the AHCA has not yet been scored, but it will be re-evaluated before it goes through the Senate.
Concern about what would happen to people with preexisting conditions hung over the negotiations, since a majority of Americans support the ACA provision that shielded cancer survivors and people with diseases, such as type 1 diabetes or rare genetic conditions, from being denied coverage or charged so much they could not afford it. A woman with an unplanned pregnancy or a parent who changes jobs and has a child with autism could be affected by a change in the law affecting preexisting conditions.
Trump himself promised shortly after the election and again this weekend that he would protect those with preexisting conditions. Appearing on “Face the Nation” Sunday, he said, “Preexisting conditions are in the bill. And I mandate it. I said, ‘Has to be.’”
US Representative Mark Meadows (R-North Carolina) leader of the Freedom Caucus, said this morning on NBC’s “Morning Joe” that the changes in the bill ensured “that people won’t have to choose between a mortgage payment and an insurance payment.”
Meadows said the bill protects those with preexisting conditions from skyrocketing costs as long as they keep continuous coverage. The bill gives states the option of creating high-risk pools for those who have a break in coverage, he said. A late change to add $8 billion to the $130 billion in the bill to fund high-risk pools was enough to gain votes from US Representatives Fred Upton (R-Michigan) and Billy Long (R-Missouri) putting the House Republicans over the top.
However, several medical and advocacy groups say the AHCA is not adequately funded to meet the needs of those with high-cost conditions; groups include AARP, the American Diabetes Association, and the American Medical Association (AMA).
“None of the legislative tweaks under consideration changes the serious harm to patients and the health care delivery system if AHCA passes,” said AMA President Andrew W. Gurman, MD, in a statement. “Proposed changes to the bill tinker at the edges without remedying the fundamental failing of the bill—that millions of Americans will lose their health insurance as a direct result of this proposal.”
Groups from Consumer Reports to the AMA have criticized the proposed reliance on high-risk pools, saying they have a poor track record of providing good access to those with costly conditions.
“High-risk pools are not a new idea,” said Gurman. “Prior to the enactment of the Affordable Care Act, 35 states operated high-risk pools, and they were not a panacea for Americans with preexisting medical conditions. The history of high-risk pools demonstrates that Americans with preexisting conditions will be stuck in second-class health care coverage—if they are able to obtain coverage at all.”