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

Congress returns to Washington next week, and House Republican Leadership maintains an ambitious agenda to pass the American Health Care Act (AHCA) despite an unclear path navigating its moderate and conservative factions.  During the in-district work period these past two weeks, the White House, House Leadership and Republican committee staff kept conversations going with the two disagreeing factions within their caucus – the moderate Republicans “Tuesday Group,” and the conservative Republicans “Freedom Caucus.”  A recently released summary of the amendment, offered by Tuesday Group member Rep. Tom MacArthur (R-NJ), includes:

  • Reinstating Essential Health Benefits as the federal standard
  • Maintain the following provisions of the AHCA:
    • Prohibition on denying coverage due to preexisting medical conditions
    • Prohibition on discrimination based on gender
    • Guaranteed issue of coverage to all applicants
    • Guaranteed renewability of coverage
    • Coverage of dependents on parents’ plan up to age 26
    • Community Rating Rules, except for limited waivers
  • The amendment would create an option for states to obtain Limited Waivers from certain federal standards, in the interest of lowering premium costs and expanding the number of insured persons. States could seek Limited Waivers for:
    • Essential Health Benefits
    • Community rating rules, except for the following categories, which are not waivable:
      • Gender
      • Age (except for reductions of the 5:1 age ratio previously established)
      • Health Status (unless the state has established a high risk pool or is participating in a federal high risk pool)
  • States must attest that the purpose of their requested waiver is to reduce premium costs, increase the number of persons with healthcare coverage, or advance another benefit to the public interest in the state, including the guarantee of coverage for persons with pre-existing medical conditions. The Secretary of HHS shall approve applications within 90 days of determining that an application is complete.

There appears to be no agreement within the Republican Caucus at this time, although reports vary.   However, this could move very quickly in the House as Republicans believe they must keep the campaign promise to repeal the Patient Protection and Affordable Care Act (“ACA”).

Next week: Federal Budget Deadline Next Week 

In addition to health care, Congress must approve federal government spending measure, as temporary “continuing resolution” expires on April 28th.  An effort is underway to pass a measure that will fund the government through the remainder of the 2017 Fiscal Year, which ends September 30th.  Republicans will need at least eight Senate Democrats to vote with them to pass a spending bill, so compromise will be required.

Further on the Horizon:  ACA Insurance Subsidies

One of the more interesting issues Congress and the Trump Administration face is what to do with ACA subsidies that were meant to help reduce cost sharing (deductibles, co-payments) for non-Medicaid eligible individuals buying insurance on the exchange.  House Republicans had successfully sued the Obama Administration in district court arguing that Congress must appropriate the money before the ACA’s Cost Sharing Reduction (CSR) subsidies could be paid.  With an injunction from the district court in place, Republicans must decide whether to actually appropriate the money in the upcoming spending bill.  Some Democrats have stated they will not vote to pass any budget without funds for the CSR program included.  What’s more, even if Republicans can pass a budget without funding the CSR subsidies, President Trump still has to decide whether to appeal the district court decision on May 22.  If he chooses to accept the district court decision and there is no appropriation, the President could unilaterally shut down the CSR subsidy program.  The President has threatened to use this court decision to bring Democrats to the negotiating table, in the event that the program is not appropriated and AHCA is not passed.

Whitfield L. Knapple, MD, FACG

Chair, ACG National Affairs Committee