Whitfield L. Knapple, MD, FACG
Chair, Legislative and Public Policy Council

In the early morning hours of Friday, July 28th, the Senate rejected a paired down, or “skinny repeal” version of the Patient Protection and Affordable Care Act (ACA).  Three Republicans: Sens. Susan Collins (R-ME), Lisa Murkowski (R-AK), and John McCain (R-AZ) joined 40 Senate Democrats to defeat this latest version of ACA repeal.  According to reports, Senate Republicans actually thought they had the 50 votes needed to pass this “skinny repeal bill.”  Vice President Pence and President Trump personally talked to Sen. McCain immediately prior to voting as well.

Click here to watch the shock on many Senators faces as Sen. McCain votes to oppose the bill.

It is important to note that while the late-night dramatics focused on Sen. McCain, many policy wonks in Washington D.C. were watching Sen. Murkowski’s vote, as reports surfaced that the Administration may be applying a lot of pressure on Sen. Murkowski to go along with the Republican bill(s).

The week actually started off strong for Senate Majority Leader Mitch McConnell (R-KY) and Republican leaders.  On Tuesday, they secured the requisite 50 votes (Vice President Pence was the tie breaker) necessary to get the bill to the Senate floor for a vote.  This required Sen. McCain to travel back to Washington D.C. after surgery and a diagnosis of brain cancer.  Things then got more interesting, as no one really knew what the “Bill” would ultimately be when it came time to vote.  The Bill started with Sen. McConnell’s latest version of the “Better Care Reconciliation Act of 2017.”  When that was voted down on Tuesday night, the Bill then became the ACA repeal bill that passed both the House and Senate in 2015 (President Obama vetoed).  That was voted down on Wednesday as well, forcing Sen. McConnell and the Trump Administration to huddle with Senate Republicans to come up with some sort of deal as the Senate voted on various political messaging amendments.  By Thursday evening, Sen. McConnell and leadership were doing the legislative equivalent of exasperated parents trying anything to get their toddlers to eat dinner before bedtime, urging their colleagues to get something/anything passed before the weekend.  By late Thursday evening, the Bill became the “Health Care Freedom Act,” or skinny repeal bill.  Elements included:

  • Repealing the ACA’s “individual mandate” to purchase health insurance, by zeroing out the penalty (beginning after December 31, 2015).
  • Repealing the ACA’s “employer mandate” by zeroing out the penalties for not providing employees any health insurance (only from January 1, 2016 to December 31, 2024).
  • Extending the moratorium on the medical device tax (December 31, 2017 to December 31, 2020).
  • Increasing for three years (2018 to 2020) the maximum contribution limit to health care savings accounts (HSA) to the amount of the deductible and out-of-pocket limitations.
  • Defunding Planned Parenthood for one year (also expanding the one-year defunding to certain other providers that provide abortions if they receive more than $1 million in federal and state funding).
  • Eliminating funding for the Prevention and Public Health Fund after FY 2018.
  • Providing $422 million in additional funding for the Community Health Center Program in 2017.
  • Amending “section 1332 of the ACA,” or the part of the ACA that Republican leadership in both the House and Senate were using to allow states to forgo essential health benefits, or other patient protections (Waiver for State Innovation). This new language gave $2 billion for states to submit or implement enhanced state innovation waivers, if the application meets certain benefit, cost-sharing, enrollment, and budgetary requirements.

The Health Care Freedom Act was ultimately voted down 49-51 at roughly 1:40 AM on Friday.

What’s next for health care reform? What is ACG doing?

Republican leadership are licking their health care reform wounds this weekend, but vowing to move forward.   There are also reports of a group of 40 House Republicans and Democrats already coming up with an alternative package.  This group is called the “House Problem Solvers” Caucus.  The next steps remain unclear, but as ACG discussed last week, Sen. McConnell and House Republican leaders may have more leverage to pass ACA and Medicaid reforms later this year (Will Sen. McConnell and Republican Leadership have a better opportunity in the fall?).  This may not be over.

What is ACG doing? ACG hopes that this failed process will allow Congress to consider other important health care reforms that ACG has been working on throughout the year.  This includes: strengthening GI patient cost-sharing and coverage protections, removing barriers to colorectal cancer screening in Medicare, allowing better access to more affordable drugs for IBD patients and others, and allowing better access to GI cognitive care.  The ACA repeal stalemate also affords ACG the opportunity to advocate for important issues impacting the GI practice, including removing unnecessary and duplicative practice management burdens, improving requirements under MACRA, Stark Law and Anti-Kickback reforms, repealing the IPAB, medical malpractice reforms, and increasing funding for GI research.

The College will continue to be the voice of clinical GI on Capitol Hill and across the country.

Whitfield L. Knapple, MD, FACG

Chair, ACG National Affairs Committee