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

On Tuesday, June 27th, Senate Republicans decided to delay the planned vote on their health reform bill, the Better Care Reconciliation Act of 2017, which was released last week.  This bill is designed to repeal the Patient Protection and Affordable Care Act (ACA), and is the Senate’s response to the House-passed bill, the American Health Care Act of 2017.  The announcement to delay the vote came on the heels of the Congressional Budget Office’s (CBO) cost and coverage estimate released on Monday, June 26.  The major headline from the CBO score:

“The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”

This led more Republicans to raise concerns and criticisms of the bill, leading Majority Leader Mitch McConnell (R-KY) to begin the process of courting support and offering to change the bill.  Earlier this year, Republican leaders scored a procedural win in allowing an ACA-repeal bill to move forward by a simple majority (as opposed to 60 votes needed to move to a final vote).  However, even getting to 50 votes has proven to be very difficult.  ACG welcomes this scenario, as the College continues to have grave concerns over the proposed policy changes to patient cost-sharing, essential health benefits, and protection for pre-existing conditions.  ACG is using this opportunity to work with like-minded organizations in getting this bill significantly improved.

Sen. McConnell’s plan heading into the July 4th congressional recess is to revise this draft in order to secure enough votes to pass the bill.  The tug-of-war is the same scenario that Speaker Paul Ryan (R-WI) experienced earlier this year, where conservatives wanted more ACA provisions repealed in order to get the costs of premiums down, but moderates supported provisions in the ACA related to insurance subsidies and Medicaid expansion.  This is one of the problems ACG has voiced concerns over and is currently speaking with policymakers about: the goal has become a test of political strategy and gamesmanship in order to get something passed, as opposed to an opportunity for getting the substantive issues correct.  What are some items that will likely be used to entice support?  What is ACG doing to get this bill improved?  What else should you know?

What may change to garner more support?

The CBO estimates that the Senate bill reduces the federal budget by $321 billion over 10 years, compared to $119 billion over 10 years that is estimated for the House bill.  This essentially gives Majority Leader McConnell roughly $200 billion of “play money” to convince more Republicans for support.  Some reported ideas:

Opioid Crisis:  It has been reported that Senate Republicans and the White House have agreed to add at least $45 billion to the repeal bill to address the opioid crisis.  This could help win over moderates.

HSAs: One reported change is allowing consumers to use Health Savings Accounts to pay for more health costs, such as insurance premiums.  This could help win over conservatives.

Skirting ACA requirements:  Reports state that conservatives support a proposal from Sen. Ted Cruz (R-TX) to allow insurers to sell plans that don’t comply with ACA requirements.  This could help win over conservatives, but could cause moderates to oppose.

Insurance Subsidies: The Senate bill scales back insurance subsidies and cuts off eligibility at 350% of the federal poverty line, compared with the ACA’s 400% threshold.  The CBO raised concerns that this change disproportionately benefits younger and healthier enrollees, causing older and poorer patients to pay significantly more for insurance.  It has been reported that the Senate could revert back to the ACA standards.  This would help to win over moderates but conversely cause conservatives to oppose.

Not repealing certain ACA taxes: Reports state that the new draft will NOT include a provision to repeal the 3.8% surtax on investments that was contained in the original version.  The CBO says that this provision would cost $172 billion across 10 years in lost federal revenue.

Planned Parenthood: One change is stripping out a provision that defunds Planned Parenthood for one year.  This option could come in a separate vote to win over both moderates and conservatives.

What is ACG doing?

The Senate won’t reconvene until Monday, July 10th, affording more time to change provisions related to cost-sharing, essential health benefits (EHBs), and protections for pre-existing conditions.  One of the reasons why Republican leadership wanted a vote prior to the July 4th recess is that the process gets more difficult the longer it drags out.  ACG is utilizing this time to educate policymakers and staff on certain aspects of the CBO analysis.  The CBO score reinforces ACG’s position that these policies will be detrimental to patient cost-sharing, EHBs, and protections for pre-existing conditions.  Some examples include:

“Out-of-pocket spending would also be affected for the people—close to half the population, CBO and JCT expect—living in states modifying the EHBs using waivers. People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services. Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state. As a result, for some benefits that might be removed from a state’s definition of EHBs but that might not be excluded from insurance coverage altogether, some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed.” CBO Report.

“Because a large portion of the population affected by additional waivers would be in states that narrow the scope of the EHBs, CBO and JCT expect insurance covering certain services to become more expensive—in some cases, extremely expensive. For example, if the EHBs were modified to drop coverage of services that have high costs and are used by few people, coverage for maternity care, mental health care, rehabilitative and habilitative treatment, and certain very expensive drugs could be at risk. Such modifications would lower premiums for many people and increase the number of people with coverage for a narrower set of benefits. But, on the basis of historical experience, CBO and JCT anticipate that the funding available to help provide coverage for those high-cost services would be insufficient in some cases even if a special program was designed for that purpose. Therefore, the agencies expect that insurance coverage for high-cost services would become extremely expensive in those areas, as it was in some places before the enactment of the ACA in 2010. A state is required to have mechanisms to reduce the chance of such outcomes as part of its waiver program under current law, but would not be under this legislation.”  CBO Report.

What else should you know?

Sen. Ron Wyden (D-OR) asked CBO to project out another 10 years of effects on Medicaid, since some of the biggest funding cuts to that program don’t kick in until 2025, and the projection released on Monday only goes until 2027.  In response, on Thursday, the CBO estimated that the Senate bill would reduce federal Medicaid spending by 35% over 20 years.

This “longer term outlook” is consistent with ACG’s rationale for endorsing and supporting the Preventive Health Savings Act (HR 2953), which would expand CBO’s scoring window to better asses the longer-term financial and health impact of the preventive health services, such as colorectal cancer screening.

ACG continues to use the additional time to improve the Senate bill on behalf of clinical GI and your patients.

Whitfield L. Knapple, MD, FACG

Chair, National Affairs Committee