After long, bitter battle, House passes AHCA—setting up a Senate showdown

House Republicans on Thursday voted 217-213 to advance legislation (HR 1628) that would repeal and replace large portions of the Affordable Care Act (ACA).

The House also voted unanimously to pass a separate bill (HR 2192) that would eliminate a provision of the AHCA that would have exempted members of Congress and their staff from the effects of any state waivers provided under the legislation.

The AHCA, which among its other provisions would significantly cut Medicaid funding, now goes to the Senate, where it may face even more difficulty winning passage in its current form.

Prior to the vote, Rep. Luke Messer (R-Ind.) said, "Today is a really big deal but it's really a green flag not a checker flag. This isn't the end of the process." He added, "In many ways it's the start. The bill will now go to the Senate. Then it will come back from the Senate." According to Vox, the Senate could ultimately draft its own bill or make significant changes to the House-approved bill.

Background: Road to the House vote

House Majority Leader Kevin McCarthy (R-Calif.) Wednesday night said Republicans had secured the 216 votes needed to pass the bill in the House after agreeing to two amendments to the American Health Care Act (AHCA):

  • One proposed last week by Reps. Tom MacArthur (R-N.J.), co-chair of the moderate Tuesday Group, and Mark Meadows (R-N.C.), chair of the conservative House Freedom Caucus, that would allow states to apply for waivers to opt out of the ACA's essential health benefits, let insurers impose health status underwriting on individuals who do not maintain continuous coverage, and allow insurers to charge older members more for coverage; and
  • Another proposed Wednesday by Rep. Fred Upton (R-Mich.) that adds $8 billion in funds to reduce health costs for people with pre-existing conditions.

According to Reuters, the House Rules Committee late Wednesday night approved the amended AHCA, setting the House up for a vote Thursday on the bill. The committee also approved separate legislation (HR 2192) that would eliminate a provision of the AHCA that exempts members of Congress and their staff from the effects of the state waivers, The Hill reports.

The latest version of the bill has not been scored by the Congressional Budget Office (CBO), which projected in March that the original bill would result in an additional 24 million U.S. residents being uninsured over the next decade.

Upton amendment details

According to Axios, the Upton amendment would add $8 billion from 2018 through 2023 to provide "assistance to reduce premiums or other out-of-pocket costs" for people with pre-existing conditions who live in a state that opted to waive the AHCA's provision that would impose a 30 percent premium penalty on individuals who do not maintain continuous coverage. In the penalty's place, states would allow insurers to impose health status underwriting on individuals who allow their coverage to lapse for at least 63 days; such underwriting is currently prohibited under the ACA.

The amendment states that the funding would be available only to individuals who live in states that opt to allow insurers to conduct health status underwriting, have a pre-existing condition, and are uninsured because they did not maintain "continuous coverage." According to the Times, the amendment does not go into further detail about who would be eligible for the funding, how the funding would cover their costs, or how much they would expect to pay in premiums.

Several insurance experts have said the additional $8 billion would not be enough to cover the costs of such individuals, the Wall Street Journal reports. And Upton himself told reporters it would be impossible to tell if the funding is sufficient without a CBO score, Politico Pro's "Pulse" reports.  

However, Upton told lawmakers on the House Rules Committee Wednesday night that he does not expect a lot of states to "seek a waiver, and in that case my amendment just covers something if maybe it happens." Upton, speaking with White House press secretary Sean Spicer, said, "It's our understanding that the $8 billion over the five years will more than cover those that might be impacted and as a consequence, keeps our pledge for those that, in fact, would be otherwise denied because of pre-existing illnesses."

Industry groups voice opposition

The legislation faces strong opposition from health care providers, patient advocacy groups and retirees.

American Medical Association President Andrew Gurman in a statement released Wednesday criticized the last-minute changes, saying they "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."

AARP in a release said the group "maintains firm opposition" to the AHCA, adding that the "Upton amendment will do little to reduce the massive premium increases for those with pre-existing conditions."

The health advocacy group Families USA in a release Wednesday called Upton's amendment a "non-solution" that would do little to improve the "'high-risk pools' that experts on both sides of the aisle have warned lead to higher costs, fewer benefits, and waiting lists rationing care for those with pre-existing conditions."

House Democratic Leader Nancy Pelosi (D-Calif.) called the latest amendments to the bill "a hoax on pre-existing conditions." She said, "If Republicans have their way, Americans with pre-existing conditions will be pushed off their insurance and segregated into high-risk pools where they face soaring cost, worse coverage and restricted care." She added, "Forcing a vote without a CBO score shows that Republicans are terrified of the public learning the full consequences of their plan to push Americans with pre-existing conditions into the cold."

(Kaplan/Pear, New York Times, 5/4; Kaplan/Pear, New York Times, 5/3; Nather, Axios, 5/3; Nather, "Vitals," Axios, 5/4; Gibson, Reuters, 5/3; Diamond, "Pulse," Politico, 5/4; Beavers, The Hill, 5/3; Peterson, Wall Street Journal, 5/3; Peterson et al., Wall Street Journal, 5/4; Howell, Washington Times, 5/3; AARP release, 5/3; Families USA release, 5/3; Sullivan/Marcos, The Hill, 5/3; Cheney et. al, Politico, 5/4; Lind, Vox, 5/4).

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