House passes AHCA, now fate of Oba­macare is in the Se­nate

Modern Healthcare - - NEWS - By Mara Lee and Matthew We­in­stock

Repub­li­can lead­ers last week cleared a ma­jor hur­dle in their pledge to undo the Af­ford­able Care Act, but they still have miles to go be­fore they can de­clare out­right vic­tory.

Se­nate GOP lead­ers im­me­di­ately tem­pered any en­thu­si­asm that may have bur­geoned after the House’s nar­row 217-213 ap­proval of the Amer­i­can Health Care Act by cau­tion­ing that they will sig­nif­i­cantly over­haul the pack­age, if not write their own ver­sion.

“As we work to ful­fill our prom­ise to our con­stituents to re­peal and re­place the law in the Se­nate, we will be guided by the im­por­tant prin­ci­ples to ad­dress costs and give Amer­i­can fam­i­lies more choices,” Se­nate Fi­nance Com­mit­tee Chair­man Or­rin Hatch (R-Utah) said in a state­ment. “At the same time, we will be work­ing to put to­gether a pack­age that re­flects our mem­bers’ pri­or­i­ties with the ex­plicit goal of get­ting 51 votes. Cou­pled with the con­straints im­posed by the bud­get rec­on­cil­i­a­tion process, we must man­age ex­pec­ta­tions and re­main fo­cused on the art of the doable as we move for­ward.”

Bud­get rec­on­cil­i­a­tion al­lows the bill to pass with a sim­ple ma­jor­ity rather than hav­ing to get 60 votes. Even so, Repub­li­cans can ill af­ford to have any de­fec­tions. They’ll also have to clear a pro­ce­dural hur­dle known as the Byrd rule, which re­quires that a bill mov­ing through bud­get rec­on­cil­i­a­tion be fo­cused on the fed­eral deficit. Democrats and some ad­vo­cacy groups in­di­cated that they will raise con­cerns that pro­vi­sions in the AHCA af­fect­ing such things as es­sen­tial ben­e­fits and pre-ex- ist­ing con­di­tions fall out­side of that scope.

This was the GOP’s first suc­cess­ful at­tempt to move leg­is­la­tion to re­peal the ACA since Pres­i­dent Don­ald Trump took of­fice. The House had twice failed to gar­ner enough votes to bring the bill to a vote.

“We can con­tinue with the sta­tus quo un­der Oba­macare. We know what that looks like,” House Speaker Paul Ryan (R-Wis.) said dur­ing the floor de­bate. “It means even higher pre­mi­ums. Even fewer choices. Even more in­sur­ers pulling out. Even more un­cer­tainty and chaos. We can put this col­laps­ing law be­hind us. ... End this failed ex­per­i­ment.”

Se­nate lead­ers will press ahead, al­beit at a more de­lib­er­ate pace. Sen. La­mar Alexan­der (R-Tenn.), chair­man of the Health, Ed­u­ca­tion, La­bor and Pen­sions Com­mit­tee, promised to fin­ish the work on re­plac­ing the ACA, “but it will take time to get it right,” adding that he wants to give states more flex­i­bil­ity on Med­i­caid, but do­ing so “in a way that does not pull the rug out from un­der peo­ple who rely on Med­i­caid.” Alexan­der said he also wants to en­sure that peo­ple with pre-ex­ist­ing con­di­tions con­tinue to have ac­cess to in­sur­ance.

The House bill em­braces the

“Cou­pled with the con­straints im­posed by the bud­get rec­on­cil­i­a­tion process, we must man­age ex­pec­ta­tions and re­main fo­cused on the art of the doable as we move for­ward.” Se­nate Fi­nance Com­mit­tee Chair­man Or­rin Hatch (R-Utah)

GOP man­date of hand­ing states more au­thor­ity in shap­ing health cov­er­age, giv­ing them the op­tion of re­turn­ing to a pre-Oba­macare in­di­vid­ual in­sur­ance ap­proach of med­i­cal un­der­writ­ing and high-risk pools.

Although the lat­est tweaks to the bill re­volved around treat­ment of high- cost cus­tomers on the ex­changes in an ef­fort to win mod­er­ate votes, the ACHA’s big­gest im­pact is ef­fec­tively end­ing the Med­i­caid ex­pan­sion after 2020. The ma­jor­ity of peo­ple who have gained cov­er­age un­der the ACA have ob­tained it through Med­i­caid— about 14.5 mil­lion peo­ple— in­clud­ing 5 mil­lion who al­ready qual­i­fied for the govern­ment health in­sur­ance but hadn’t pre­vi­ously ap­plied for it.

“Ru­ral hos­pi­tals will close, 2 mil­lion jobs will be de­stroyed across Amer­ica, and all of this to give a mas­sive tax cut to the rich­est in Amer­ica,” House Mi­nor­ity Leader Nancy Pelosi said. “It’s Robin Hood in re­verse.”

Be­yond the de­bate over Med­i­caid, which has some GOP gov­er­nors con­cerned as well, elec­tion math be a fac­tor. Next year, eight GOP sen­a­tors face re-elec­tion, in­clud­ing Sens. Jeff Flake (R-Ariz.) and Dean Heller (R-Nev.). Both hail from Med­i­caid ex­pan­sion states. The rest of the GOP cau­cus won’t face re­elec­tion un­til 2020 or 2022, free­ing them from some of the po­lit­i­cal pres­sure that faced their col­leagues in the House.

If a bill clears the Se­nate, it will have to rec­on­ciled with the House bill. The Se­nate process is ex­pected to take sev­eral weeks.

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