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

On Thursday, House Republican leaders delayed a vote on their revised Patient Protection and Affordable Care (ACA) repeal bill to take place next week at the earliest.  White House officials, after striking a deal with conservatives, had publicly raised expectations that the vote would occur this week.  The White House then privately pushed House Speaker Paul Ryan (R-Wis.) to vote on the measure at hand.  President Trump had hoped for a major legislative victory before Saturday, his 100th day in office.  However, House Republicans are still struggling to secure the votes within their caucus.

In other news, both the House and Senate overwhelmingly passed a bill on Friday to fund the government for one week, to avert a government shutdown at midnight (4/29). Congress is expected to pass a broader spending package next week to fund the government through September 2017.

A negotiated amendment brought health reform back into the spotlight this week.  The changes were negotiated by Freedom Caucus chairman Mark Meadows (R-NC) and Tom MacArthur (R-NJ), co-chair of the moderate Tuesday Group. Under the agreed proposal, states would be permitted to waive some of the ACA’s minimum coverage requirements and consumer protections, so long as they certified that they could offer an alternative that reduces premiums, enhances competition, or increases the number of people with coverage.  When the House tried to pass the American Health Care Act (AHCA) last month, it was the conservative Freedom Caucus that opposed the bill.  This time, however, it appears the moderate Tuesday Group members are causing trouble for Speaker Ryan and the White House.  Reports also surfaced that Rep. MacArthur negotiated the amendment without the full blessing of the Tuesday Group caucus.  House Republican leadership needs 216 votes.  Since no Democrats are expected to support the measure, Speaker Ryan can only afford to lose 22 members.

The Amendment allows states to waive certain ACA requirements.  States may apply for the following changes:

  • Changes to the age band rating ratio
  • Changes to essential health benefits (EHBs) so that they are specified by the state and not those in the ACA
  • Changes to allow states to charge individuals with preexisting conditions more if certain conditions are met

Waivers are by default approved unless the Secretary notifies the state no later than 60 days after the submission that the application has been denied.  Applications must specify how the waivers will achieve one or more of the following:

  • Reduce average premiums in the state
  • Increase enrollment in the state
  • Stabilize the market in the state
  • Stabilize premiums for individuals with preexisting conditions
  • Increase the choice of health plans in the state

The Amendment maintains protections against gender rating and preexisting conditions.  Though the measure would technically preserve the ACA’s guarantee of coverage for people with pre-existing conditions, it also allows insurers in those states to increase premiums if there is a gap in coverage. To offset that risk, the bill includes a $130 billion fund meant to help keep premiums down for people with pre-existing conditions.

The Congressional Budget Office is not expected to release the latest score of the new draft for a few weeks, congressional sources said Thursday. The CBO score for an earlier version of the text estimated that an additional 24 million individuals could go uninsured over the next 10 years.

ACG’s Take: Opposition to Changes in Essential Health Benefits and Pre-Existing Conditions
Among ACG’s most significant concerns with House Republican plans is the movement away from essential health benefits and preventive services, as well as making it more difficult for those with pre-existing conditions to afford health insurance.  The College is prepared to work with the U.S. House and Senate to make any necessary improvements.

Whitfield L. Knapple, MD, FACG

Chair, ACG National Affairs Committee