GOP Preps ACA Repeal-and-Replace Bill for Second Try

April 26, 2017

Insurers in Affordable Care Act (ACA) marketplaces could charge individuals higher premiums on the basis of preexisting conditions in a proposed amendment to a repeal-and-replace bill that House Republicans want to resurrect.

Organized medicine has rallied against the amendment to the bill, called the American Health Care Act (AHCA).

Revival of the AHCA comes during a bubbling, boiling week of politics when a divided Republican party in control of Congress, its Democrat opponents, and the Trump administration are trying to pass a spending resolution to avert a government shutdown that otherwise would begin this weekend.

The proposed amendment to the AHCA, drafted by Rep. Tom McArthur (R-NJ), would allow each state to waive the ACA's community rating provision, which forbids insurers from raising premiums for enrollees with preexisting conditions. States could waive community rating as long as they participate in a high-risk insurance pool program that would make coverage more affordable for such individuals. Insurers still would be required to guarantee coverage of people with preexisting conditions, and they could not charge women more simply because they are women.

McArthur co-chairs the informal caucus of moderate House Republicans called the Tuesday Group. His proposed amendment represents a concession to the Freedom Caucus, a group of staunchly conservative House Republicans who heretofore have opposed the AHCA because it strikes them as not going far enough to repeal the ACA. Without their support, and that of some moderate Republicans, House Speaker Paul Ryan (R-Wis) didn't have enough aye's to pass the AHCA in a vote scheduled for March 24, so he pulled it from consideration.

The Freedom Caucus today announced that it will now support the AHCA because of the McArthur amendment. However, its provisions risk losing more votes from moderate Republicans, who want to preserve insurance coverage gains and protections under the ACA. The Congressional Budget Office estimates that under the AHCA, the number of uninsured Americans will increase to 24 million by 2026.

A more conservative-leaning, repeal-and-replace bill also faces a harder time in the Senate, where Democrats have enough votes to mount a filibuster.

The new tweaks proposed for the AHCA reprise other nods toward states' rights that House Republicans have previously floated. States could define what essential benefits belong in health plans sold on the ACA marketplaces, or exchanges, as opposed to what the ACA requires. The ACA's 10 essential benefits include hospitalization, preventive care, prescription drugs, maternity care, and mental health care. States might want to shrink the list so insurers could offer stripped down, less expensive plans. States also could allow insurers to charge older Americans higher premiums than those allowed under the ACA. These changes are designed to help insurers make money as opposed to lose money on the exchanges, and keep them there.

Amendment Makes a Bad Bill Worse, Say Medical Societies

House Democrats are heaping scorn on the McArthur amendment just as they have on the original version of the AHCA. "Under the Republican plan, families will be slammed with brutal premium increases and massive surcharges for the health coverage their loved ones desperately need," House Minority Leader Nancy Pelosi (D-Calif) said in a news release. "Many would lose access to affordable health coverage entirely." The amendment's exemption of members of Congress from state waivers of ACA provisions such as community rating, Pelosi said, illustrates the "monstrous immorality" of the bill.

In more restrained rhetoric, major medical societies also are criticizing the McArthur amendment. "This amendment would make the harmful AHCA even worse by creating new coverage barriers for patients with preexisting conditions and weakening requirements that insurers cover essential benefits," said Jack Ende, MD, president of the American College of Physicians (ACP), in a letter to Congressional leaders.

Today, five more medical societies went on record opposing the McArthur amendment — the American Academy of Family Physicians, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association. In a letter to Ryan and Pelosi that the ACP also signed, the groups said the compromises in the amendment "are built on the flawed foundation of the [AHCA]."

These same medical societies had criticized the original version of the bill for, among other things, ending Medicaid expansion in 31 states, limiting federal contributions to state Medicaid programs by turning them into block grants, decreasing premium subsides for exchange plan enrollees, and eliminating cost-sharing reductions (CSRs), which reduce deductibles and other out-of-pocket expenses for lower-income individuals.

Loss of federal funding for the CSRs, which Congressional Democrats are trying to prevent, once looked like it might trigger a showdown on the spending bill that lawmakers need to pass to keep the government open for business. However, the Trump administration is telling lawmakers that the CSR money will keep flowing, Politico reported today.

Follow Robert Lowes on Twitter @LowesRobert

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