Can Repub­li­cans com­pro­mise with each other to pass ACA re­peal bill?

Modern Healthcare - - NEWS - By Har­ris Meyer

It’s make-or-break time for Repub­li­can ef­forts to re­peal and re­place the Af­ford­able Care Act. And right now it’s look­ing more like break.

Con­gres­sional GOP lead­ers are scram­bling to come up with a com­pro­mise be­tween con­ser­va­tives who want to scale back pre­mium sub­si­dies and Med­i­caid cov­er­age in the al­ready-lean Amer­i­can Health Care Act, and more mod­er­ate mem­bers and gover­nors who want to see more gen­er­ous ben­e­fits.

The bill is up for a House floor vote Thurs­day. But the Se­nate is un­likely to pass the bill in its cur­rent form. Repub­li­cans in both cham­bers are threat­en­ing to vote no if their de­mands aren’t met, and they can af­ford few if any de­fec­tions since no Democrats are ex­pected to sup­port it.

Con­gres­sional GOP lead­ers had hoped to pass their bill by early April, be­fore mem­bers head back to their dis­tricts for the Easter re­cess. But that now looks highly un­likely. So they may face an­other round of tense en­coun­ters with con­stituents up­set about the prospect of los­ing their ACA cov­er­age. The wild card is Pres­i­dent Don­ald Trump, who has so far sent mixed sig­nals. Last week, he touted the bill, say­ing Amer­i­cans should be able “to pur­chase . . . plans they want, not the plans forced on them by our gov­ern­ment.”

But he also ac­knowl­edged on Fox News last week that his work­ing-class sup­port­ers would do less well un­der the bill.

A GOP lob­by­ist said House lead­ers know the cur­rent bill is “dead as a door­nail” in the Se­nate be­cause con­ser­va­tives likely aren’t will­ing to com­pro­mise with Se­nate mod­er­ates.

GOP anx­i­eties spiked fol­low­ing last week’s re­lease of a Con­gres­sional Bud­get Of­fice re­port pro­ject­ing the AHCA would lead to 24 mil­lion more unin­sured Amer­i­cans by 2026, with a dis­pro­por­tion­ately neg­a­tive im­pact on low­er­in­come and older peo­ple. The bill would drive up in­di­vid­ual-mar­ket pre­mi­ums by an es­ti­mated 15% to 20% in 2018 and 2019, though rates would drop in later years.

On the other hand, it would cut the fed­eral deficit by $337 bil­lion over 10 years, largely through slash­ing Med­i­caid spend­ing by $880 bil­lion, or 25%, and shrink­ing the num­ber of ben­e­fi­cia­ries cov­ered. The bill nar­rowly passed the House Bud­get Com­mit­tee last week, with three con­ser­va­tive Repub­li­cans vot­ing against it. The House Rules Com­mit­tee vote could add amend­ments that win over con­ser­va­tives. Those could in­clude al­low­ing faster re­peal of ex­tra fed­eral pay­ments to states for ex­pand­ing Med­i­caid; giv­ing states Med­i­caid block grants; and im­pos­ing work re­quire­ments on ben­e­fi­cia­ries.

But a group of Se­nate Repub­li­cans told the White House last week they wanted the bill changed to boost pre­mium tax cred­its for poorer, older Amer­i­cans, who would face huge out-of-pocket cost in­creases un­der the cur­rent leg­is­la­tion. They want the tax cred­its to be based on in­come and ge­o­graphic lo­ca­tion as well as age, since pre­mi­ums of­ten are higher in ru­ral ar­eas.

Mean­while, GOP sen­a­tors and gover­nors are press­ing for re­mov­ing or chang­ing the bill’s phase­out of fund­ing for the ACA’s Med­i­caid ex­pan­sion to low-in­come adults. They also seek re­vi­sions in the bill’s caps on to­tal Med­i­caid pay­ments to the states, which the CBO said could lead to cuts in eligibility, cov­ered ser­vices and provider pay­ment rates. And they seek more flex­i­bil­ity in how they run their Med­i­caid pro­grams. The hospi­tal in­dus­try is lob­by­ing hard against the GOP’s capped Med­i­caid fund­ing model.

Changes in the tax credit and Med­i­caid pro­vi­sions could sharply boost the bill’s price tag, re­duc­ing or eras­ing its promised deficit re­duc­tion and en­dan­ger­ing its abil­ity to meet the Se­nate’s strict bud­get rec­on­cil­i­a­tion rules. De­spite the GOP tra­vails, con­ser­va­tive ob­servers ex­pect Repub­li­cans to get their health­care bill over the fin­ish line.

“Repub­li­cans have been run­ning for seven years on re­peal­ing and re­plac­ing the ACA,” said Tom Barker, a part­ner at Fo­ley Hoag who led GOP pres­i­den­tial can­di­date Mitt Rom­ney’s health­care tran­si­tion team. “This is their only chance. Will they just give up that op­por­tu­nity? At the end of the day, I don’t think they will.”


Sen. Mitch McCon­nell briefs re­porters last week on the GOP agenda.

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