Whitfield L. Knapple, MD, FACG
Chair, ACG National Affairs

House Republicans and President Trump were forced to cancel a House vote on the American Health Care Act (AHCA) on Friday afternoon, after it became clear that there were not enough votes to pass the bill. The vote was originally scheduled for Thursday, 7 years to the day that the Patient Protection and Affordable Care Act (ACA) was signed into law.  On Thursday evening, President Trump urged the House to hold the vote on Friday, even without a clear picture of whether or not it would pass.  According to some insiders, the House Republicans were just 8 votes shy of passing the bill on Thursday evening.  By Friday afternoon, however, the vote count for those supporting started to get worse as both conservative and moderate Republicans began jumping ship for various reasons.

The week began with House Republican Leadership unveiling an amended version of the bill, “AHCA 2.0,” to both woo conservative Republican House members into supporting the bill, and to keep moderate Republicans from opposing.  As discussed over these past few weeks, ACG had been closely monitoring this political balancing act led by Speaker Paul Ryan (R-WI) and was preparing for this outcome.  As the week progressed, President Trump and Speaker Ryan were brokering deals with House Republicans on this amended version of the AHCA, thus finalizing an “AHCA 3.0” by the week’s end.

ACG’s Take: Opposition to Changes in Essential Health Benefits

Among ACG’s most significant concerns with the AHCA was the movement away from essential health benefits and preventive services.  The College did not support these provisions and was prepared to work with the U.S. Senate to make any necessary improvements.

What are “essential health benefits” or EHBs?  The ACA requires non-grandfathered health plans in the individual and small group markets to cover essential health benefits (EHB), which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative/habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care.

The original version of the AHCA gave states the flexibility to offer EHBs in the Medicaid program, in addition to limiting the amount the federal government reimburses states for expanding Medicaid and enrollment requirements.

House Republicans further eroded EHB requirements in the individual private market in the “AHCA 3.0” plan.  Specifically, via an amendment that would have allowed states to “define essential health benefits” for those individuals getting subsidized health insurance (via a tax credit) to purchase an individual market plan.  The provision did not impact group plans or Medicare. The provision may have helped states qualify for tax credits, some plans that are limited but cheaper.  However, the provision was another example of the AHCA erosion of EHBs for those GI patients needing financial assistance for comprehensive plans and specialty care— the Medicaid population and individual market plan enrollees.  Further, once a service is no longer considered an EHB, protections on insurer annual or lifetime spending caps are no longer applicable.  Thus, an individual could have a plan without some of these EHBs, or annual and life-time spending caps for any service that was previously considered an EHB.

Next steps: Is there appetite for more?

Now that the bill has failed to pass in the U.S. House, it is unclear what the next steps are for ACA repeal and replace.  It is also unclear whether President Trump, House, and Senate Republican leaders even want to revisit this politically-charged hot potato that is health care reform.  On Thursday evening, President Trump called for the House to make a decision on the bill on Friday, and if it fails, to move on from repealing the ACA health care reform altogether.  The U.S. Senate also has a full schedule ahead, including voting on the nomination of Supreme Court pick Neil Gorsuch, the Easter recess, as well as the need to extend a fiscal 2017 continuing resolution (keep the Federal Government operating) that expires April 28th.

ACG has been preparing for this outcome, and believes it may afford the opportunity to work with Congress in getting some of ACG’s top priorities included in smaller, less divisive health care packages supported by both Republicans and Democrats.  ACG Governors will be in Washington D.C. and on Capitol Hill in early April advocating for ACG members and GI patients.  This includes strengthening preventive services for GI patients and reducing practice management burdens for GI practices.  The timing is a great opportunity to engage with members of Congress and staff as they begin to plan for the next steps of ACA repeal and health care reform.

Whitfield L. Knapple, MD, FACG

Chair, ACG National Affairs Committee