Health Care Legislation
As reported in the Update, the House approved the American Health Care Act (AHCA, H.R. 1628) on with only Republican votes. In addition to replacing significant parts of the Affordable Care Act (ACA), that bill would fundamentally restructure and cut the Medicaid program. (See the Update and the list of articles and resources below.)
Status of Bill. Since the last issue of the Washington Update (May 24) the House bill has been transmitted to the Senate and has been "read" twice meaning it is now ready for consideration on the Senate Floor, bypassing any committee consideration. Senate amendments to the House bill are being developed by separate groups of Senators in private meetings, and are not likely to be unveiled until shortly before the bill goes to the Floor. See Republican Senators Unaware of Health Care Details (Roll Call, June 12). Senate Majority Leader Mitch McConnell (R-KY) has indicated that he would like to hold a vote on the bill by the end of June, just before a congressional recess for Independence Day. Before it can be taken up, however, there must be a "score" (cost and impact analysis) from the Congressional Budget Office (CBO), which could take well over a week to get. It has been reported that pieces of the prospective bill are being sent to CBO for evaluation so the vote can be taken before the recess.
Medicaid Expansion. A group of Senators led by Senator Portman (R-OH) have proposed phasing out the ACA Medicaid expansion over seven years, as opposed to the abrupt end to the expansion in the House bill. Some observers are predicting that the Senate bill will include a five-year phase out. On the other hand, some of the most conservative Senators would like to end the Medicaid expansion more quickly.
Medicaid Caps. Perhaps because the Medicaid expansion has received a lot of attention or has created confusion about the Medicaid aspects of the House bill, very few Senators have expressed concern about the bill's Medicaid caps. Among those who have paid attention to this issue, there reportedly have been discussions about ways to make the Medicaid caps more generous, and/or to avoid giving a permanent advantage to states that have expanded Medicaid (since their base-year amount would be higher). Medicaid advocates have been working to educate Senators and their staffs about how AHCA's Medicaid caps would affect states and Medicaid beneficiaries. Advocates have been conveying the message that any form of cap on federal Medicaid spending would be harmful because it changes the nature of the program, shifting costs to states, providers and beneficiaries, and making it easier for Congress to cut Medicaid spending in the future when they need a "pay-for" for other legislation.
Waivers of Essential Health Benefits and Community Rating. The House bill would allow the Department of Health and Human Services to let states waive the ACA's ten Essential Health Benefits (EHBs), and instead establish their own benefit requirements. States would also be allowed to waive the ACA's requirement that individuals not be charged more for insurance because they have a pre-existing condition ("community-rating"). As a result of these changes, it may be very difficult for consumers to find affordable plans that meet their health needs. Moreover, because the prohibition on annual and lifetime coverage limits and the limits on out-of-pocket spending are applicable only to Essential Health Benefits, these protections could be greatly weakened under the House bill. It has been reported that the Senate bill will allow states to waiver EHBs but not community rating. This could still have the effect of increasing premiums for people with pre-existing conditions because they would need plans that cover more services and so would be more expensive. See If Senate Republican Health Bill Weakens Essential Health Benefits Standards, It Would Harm People with Pre-Existing Conditions (Center for Budget and Policy Priorities, June 12).
Reproductive Health. The House bill would prohibit Medicaid reimbursement for Planned Parenthood clinics for one year, which would create financial hardship for many of the clinics. In addition, the House bill would prohibit the use of premium tax credits to purchase any health care plan that covers abortion (except for pregnancies resulting from rape or incest or that threaten the life of the mother). The Senate Parliamentarian has warned the leadership that the latter provision might not comport with the rules of reconciliation, so might be subject to a "point of order" that would strike it from the bill.
Outlook. The AHCA is a "reconciliation" bill. As such, it enjoys special procedural privileges if it meets specific criteria. Namely, it can proceed to a vote with the approval of only 51 votes, rather than the 60 usually needed to advance Senate legislation. Since there are only 52 Republican Senators, and the bill is not expected to get any Democratic support, the Republicans can afford to lose no more than two votes. (In his role as President of the Senate, Vice-President Pence would break a 50-50 tie.) Senators Lisa Murkowski (R-AK) and Susan Collins (R-ME) have expressed reservations about the House bill's one-year ban on Medicaid reimbursement for Planned Parenthood. On the other hand, some Senators have indicated that they would not vote for the bill if it does not include the abortion-related restriction on the use of premium tax credits. Republican Senators from states that expanded Medicaid have expressed reservations about the rate of phasing out the Medicaid expansion. A few Senators have expressed concern about the restructuring (capping) of Medicaid. Despite the small margin of error, it is still quite possible that Senator McConnell will figure out a way to get the necessary votes. He might employ procedural tactics that would result in a vote before Democrats have had a chance to see the bill's language, thus making it difficult for Democrats to argue against it or offer appropriate amendments. In addition, it is expected he will hold the vote before he is certain that the bill will pass, which would put tremendous last-minute pressure on undecided Senators to vote for the bill.
If the bill passes the Senate, then the House could either accept the Senate's bill, or a House-Senate conference committee would be formed to work out a compromise. If both bills contain the Medicaid caps and cuts, then those provisions likely would remain in any final legislation.
For more information about the AHCA and its impact, see -
Summaries of AHCA:
- Summary of the American Health Care Act as passed by the House May 4, 2015 (Kaiser Family Foundation)
- Interactive tool from the Kaiser Family Foundation, which provides a side-by-side comparison of current law (ACA) and the AHCA (and other bills).
- Graphic side-by-side comparison of current law (ACA) and the AHCA from the LA Times.
Analyses of AHCA Impact:
- Restructuring Medicaid in the American Health Care Act: Five Key Considerations (Kaiser Family Foundation, 5/15/17)
- Per Capita Caps Could Reduce Funding for Children Covered by Medicaid: All 50 states and DC would receive fewer Medicaid dollars for non-disabled children.(Avalere, 5/18/17; links to full report)
- At Risk: Medicaid's Child-Focused Benefit Structure Known as EPSDT (Georgetown Center on Children and Families, June 2017)
- Factors Affecting States' Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? (Kaiser Family Foundation, June 9)
- What's really at stake in the Medicaid spending debate, from Drew Altman, President and CEO, Kaiser Family Foundation (June 2)
- Impact of per capita caps on home and community-based services (Center on Budget and Policy Priorities, 5/18/17) (includes state-specific information on the number of people receiving Medicaid home and community-based care)