Republicans in the House of Representatives celebrated their whisker-thin win Thursday to pass a bill that could begin the process of overhauling the health reform law known as Obamacare.
But their celebration might be short-lived because it’s now the Senate’s turn to craft its version of revisions to the controversial law formally known as the Patient Protection and Affordable Care Act.
And influential members of the Senate are already saying their version could look significantly different than the House version.
Sen. Susan Collins (R-Maine) said the House bill poses “more questions than answers about its consequences.” She said there should be “no barrier for coverage” for people with pre-existing medical conditions and that the House’s tax credits “do not adequately take into account income levels” or regional differences in health costs, the Associated Press reported.
Collins and Sen. Lisa Murkowski (R-Alaska) also have opposed cuts to federal money for Planned Parenthood. The House bill passed Thursday prevents federal payments for a year to Planned Parenthood, which provides abortions but, by law, can’t use federal funds for them, the news service reported.
And Sen. Rob Portman (R-Ohio) said, “I’ve already made clear that I don’t support the House bill as currently constructed.” He said he was particularly worried about proposed cuts to Medicaid, including funds for treating people with opioid drug problems. He said he’d make sure that “those who are impacted by this epidemic can continue to receive treatment,” the AP reported.
The Washington Post reported disagreement among Senate Republicans on how to even begin the process of drafting their bill. For instance, the Senate’s rules-keeper can’t review the legislation until the nonpartisan Congressional Budget Office (CBO) submits its cost estimate, which could take weeks, the newspaper said.
Illustrating GOP senators’ concern, Lindsey Graham (R-S.C.) tweeted Thursday: “A bill — finalized yesterday, has not been scored [by the CBO], amendments not allowed, and 3 hours final debate — should be viewed with caution.”
Whatever the outcome in the Senate, any changes it makes to the House bill would lead to a conference by members of both chambers to work out their differences.
Repeal and replace a seven-year GOP goal
The House Republicans’ bill passed Thursday with one vote to spare — 217-213.
The Affordable Care Act was arguably former President Barack Obama’s biggest domestic achievement. President Donald Trump has made repeal and replace a priority of his new administration.
Ever since enactment of the Affordable Care Act — sometimes called Obamacare — in 2010, Republicans have pushed to repeal the law, the largest expansion of health care in 50 years.
Republicans have long contended that the law is an unprecedented overreach of federal authority. The GOP found the provision requiring most Americans to maintain health coverage, or pay a penalty, particularly onerous.
Many state GOP governors and attorneys general also balked at the law’s mandated Medicaid expansion, resulting in lawsuits that eventually led to a U.S. Supreme Court ruling making Medicaid expansion optional.
Medical and patient groups criticized the latest iteration of the House bill, saying it weakened certain Obamacare patient protections.
The House Republicans’ proposal removes funding for some core provisions of Obamacare and relaxes insurance market rules.
Some key elements of the House plan include:
- The bill drops Obamacare’s so-called individual insurance mandate, which requires most Americans to have insurance or pay a penalty.
- Insurers can’t limit access to health insurance coverage for people with pre-existing conditions. However, states can apply for waivers from federal rate-setting rules, allowing insurers to charge people higher rates if they fail to maintain continuous insurance coverage.
- The bill establishes a fund to help states create high-risk pools to cover people with costly health conditions who are priced out of the individual insurance marketplace.
- It replaces the current system of income-based premium tax credits with a simplified schedule of refundable tax credits based on a person’s age.
- It ends cost-sharing subsidies. These subsidies help reduce copays and deductibles for certain low-income Obamacare customers.
- It nearly doubles the amount of money Americans can sock away in health savings accounts.
- It halts further Obamacare Medicaid expansions, overhauls the way Medicaid is funded and allows states to impose a work requirement on certain Medicaid recipients.
Republicans question the financial health of Obamacare
Republicans say the Affordable Care Act is unsustainable. With average health insurance premiums spiking at double-digit rates in 2017 and more health insurers deciding to exit the Obamacare marketplaces, GOP lawmakers argue that it’s time to intervene before the law collapses.
Economist Anthony LoSasso, a professor of health policy and administration at the University of Illinois at Chicago, said the House GOP proposal represented “the best hope” to prevent the individual insurance market’s downward spiral.
“There’s good reason to think that this actually rejuvenates markets, causes insurers not to want to abandon it,” he said.
The Republican push to replace the Affordable Care Act comes as more insurers drop out of the program or curb their participation for 2018.
Aetna Inc. said it would pull out of Virginia’s individual health insurance marketplace for 2018, according to news reports. Medica, the only remaining Obamacare insurer that offers statewide coverage in Iowa, warned that it would quit unless it gets help from the state or federal government, according to multiple reports.
Many health policy analysts say the House Republican measure could lead to higher premiums for poor, older and sicker Americans.
The proposal bans insurers from limiting “access to health coverage” for people with pre-existing conditions. But, states could seek waivers from federal rate-setting rules. In those states, insurers could charge people with pre-existing conditions more money for that coverage unless they stay continuously enrolled in an insurance plan.
Christine Eibner, a senior economist at the RAND Corporation, said it might be hard for people to maintain continuous coverage in some circumstances.
“For example, if a person loses a job, he or she might lose access to employer-sponsored coverage while simultaneously experiencing a big income loss,” she said. That person might “gamble on going without insurance for a time” and could be at risk of future rate increases.
Eibner said older and lower-income individuals “might be at particular risk of going without coverage due to affordability issues, and then facing rate increases down the road.”
The Kaiser Family Foundation has details on the American Health Care Act.