The House of Representatives voted 217-213 here Thursday to repeal and replace the Affordable Care Act (ACA) with a plan that critics say could throw millions of people off of health insurance and cause premiums to rise steeply for older Americans.
WASHINGTON -- The House of Representatives voted 217-213 here Thursday to repeal and replace the Affordable Care Act (ACA) with a plan that critics say could throw millions of people off of health insurance and cause premiums to rise steeply for older Americans.
The vote on a revised version of H.R. 1628, the American Health Care Act (AHCA), came just before House members headed out of town for a week-long recess. The measure now heads to the Senate, where many observers say it will have a tough time getting through.
Under the original version of the bill, the Congressional Budget Office (CBO) estimated that 24 million people would lose their health insurance as of 2026 if the bill were passed; it would also reduce the deficit by $337 billion over the same period, CBO said. However, the current bill -- which has several revisions -- was voted on too quickly for the CBO to develop a revised estimate.
Mandates Eliminated
The AHCA would eliminate the taxes and mandates that financed the ACA -- including the individual and employer mandate penalty -- allow insurers to charge older adults and young people less, and replace subsidies based on need with flat tax credits based primarily on an age. Over time, the plan would repeal the Medicaid expansion and put a ceiling on the entitlement program by shifting its structure to a per-capita block grant, which would increase as enrollee size increases. The bill would also freeze federal funding for Planned Parenthood.
The original AHCA bill was scheduled for a vote on March 24, but it was pulled at the last minute by House Speaker Paul Ryan (R-Wisc.) after he determined he did not have enough votes to pass it. Since then, Republicans made several changes to their bill in order to attract recalcitrant members of their party, both moderates and conservatives.
These included:
- An amendment by Rep. Tom MacArthur (R-N.J.) that would allow states to opt out of requiring insurers to cover the ACA's list of "essential health benefits"; instead, states could develop their own lists of what benefits they considered essential. The amendment also would allow states to charge more for 1 year to patients with pre-existing conditions if they have been without insurance coverage for 63 days or more. This type of medical underwriting would be done in lieu of a 30% penalty called for under the law for patients who re-enroll in health insurance after such a lapse in coverage. States who opt to allow medical underwriting also would have to set up high-risk pools for patients with high costs due to pre-existing conditions.
- An amendment by Reps. Fred Upton (R-Mich.) and Billy Long (R-Mo.) that would provide states with an extra $8 billion over 5 years to set up high-risk pools to cover patients with high costs due to pre-existing conditions, in addition to the $130 billion already in the bill that states could use for that purpose. Although no CBO estimate is available, an estimate from the Center for American Progress, a left-leaning think tank here, found that states would need an extra $200 billion for the high-risk pools to be adequately funded, assuming that 5% of patients in the individual and small-group markets end up in the pools.
- An amendment by Rep. Martha McSally (R-Ariz.) to prevent members of Congress from being exempted from the AHCA. The AHCA originally exempted Congress members from being affected by state waivers.
Rep. Phil Roe, MD (R-Tenn.), an ob.gyn., said he was voting for the bill because the ACA cannot be fixed. "The whole [ACA] plan is so complicated it's impossible," he told MedPage Today in a phone interview. "There are people out there who got helped by [the ACA], no question, but they'll get helped by this bill also."
More than half of those who have coverage through the ACA "have out-of-pocket costs and copays so high that they don't go for healthcare," he said. "If you have a health insurance card but you can't use it, it's not of much value to you. So we have to try to get the costs down."
Medical Groups Pan the Measure
Medical organizations' comments on the bill were overwhelmingly negative. "None of the legislative tweaks under consideration changes the serious harm to patients and the healthcare delivery system if AHCA passes," American Medical Association president Andrew Gurman, MD, said 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."
"This bill ... will severely limit access to services for the more than 70 million people who rely on Medicaid for effective health coverage – and locks states' funding to what they spent on Medicaid in 2016," Margaret Murray, CEO of the Association for Community Affiliated Plans, said in a statement. "If history is any guide, at some point states will be faced with a choice between denying care to people who need it, or blowing a hole in their budget ... Should this bill move to the Senate, we encourage senators to start the debate around health reform where it should begin: with a clean sheet of paper."
"We are very disappointed that the most recent version of the legislation does not guarantee insurance coverage for emergency medical care," Rebecca Parker, MD, president of the American College of Emergency Physicians, said in a statement. "This latest version of the new healthcare legislation does little to improve the health of the nation and will lead to more Americans not having any form of healthcare coverage."
Heated Floor Debate
Debate on the House floor was heated. "How did we get to this point?" asked Rep. Michael Burgess, MD (R-Texas), an ob/gyn. "The ACA is simply not working for the American people; it is limiting choices, it is raising costs, it is leaving millions without access to care. The ACA has left the individual market in shambles and is driving insurers away from offering coverage."
"Pathetic -- that is the word to describe this process and this bill," said Rep. Jim McGovern (D-Mass.). "If the American people could sue Congress for malpractice, my Republican friends would be in deep trouble. How could you do this to the people you represent? You're allowing insurance companies to discriminate against people with preexisting conditions? What is wrong with you guys?"