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

Last week, ACG informed you that the efforts to repeal and replace the Patient Protection and Affordable Care Act (“ACA”) have returned, after a plan drafted by Republican Senators Lindsey Graham (SC), Bill Cassidy, MD, FACG (LA), Dean Heller (NV), and Ron Johnson (WI) was being touted as the last opportunity to pass health reform in the Senate this year.  They are correct, as September 30th is the deadline to use the legislative budget process to pass any repeal bill by a simple majority.  This week, Senate Majority Leader Mitch McConnell (KY) announced that he will try and force a vote next week.  It is still unclear whether Senate Republicans have the votes needed in order to pass this bill via a simple majority.  All eyes are on Sens. Susan Collins (ME), Lisa Murkowski (AK), and Dan Sullivan (AK).  Sen. Rand Paul (KY) has already voiced opposition.  On Friday, Sen. McCain announced that he will oppose the bill as well, meaning that only one more defector can be afforded in order to pass the bill with the benefit of Vice President Mike Pence’s tie-breaking vote.

There has been much arm-twisting and many private meetings this week.  The Congressional Budget Office will release the estimates of the repeal plan early next week, but it won’t be able to produce a detailed analysis of how the legislation would impact health insurance coverage, access to care, and costs to the federal budget for several weeks (after the Sept. 30 deadline).

ACG’s position: As the College has previously stated, we feel that this process has become a test of political strategy and gamesmanship in order to get something/anything passed, as opposed to an opportunity for Congress to improve substantive issues with the ACA, and acknowledge that there is much to improve.  ACG remains very concerned over the rushed process, lack clarity, and lack of an objective CBO analysis on how the cuts to Medicaid would impact the states — specifically, how states would require coverage for necessary preventive services, implement protections for those with pre-existing conditions, or impose cost-sharing requirements.  Medicaid is a growing source of patient volume for ACG members’ practices.  It is unclear how cuts to Medicaid would impact these practices and these patients.  The bill encourages state flexibility and the ability to waive certain ACA coverage requirements in order to deliver better insurance products to state residents.  This has raised the alarm for many organizations, as states can simply waive these coverage requirements.  The bill’s supporters acknowledge this risk.  They claim, however, in order to receive the waiver and grant, the state would have to describe “how the state intends to maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions if such waiver is approved.”  The state may also choose to describe how the funding assistance will reduce out-of-pocket costs, such as co-payments, coinsurance, and deductibles, of individuals enrolled in plans offered in the individual market; or to provide payments for health care providers.  The flip-side to flexibility, however, is uncertainty and lack of clarity.  For example, how are “adequate” and “affordable” coverage defined when the bill also allows states to waive restrictions on setting health premiums based upon health status?  While this can be done via the regulatory process, the legislation still needs to set a blueprint for the regulators.

Of note- Something to watch: A group of ten Governors sent a letter to Sen. McConnell, urging that Congress look towards stabilizing the insurance market rather than focusing efforts on this current ACA repeal and replace bill.  The Republican governors included: John Kasich (OH), Brian Sandoval (NV), Charlie Baker (MA), Phil Scott (VT), as well as independent Bill Walker (AK). The Democratic governors included: John Hickenlooper (CO), Tom Wolf (PA), John Bel Edwards (LA), Terry McAuliffe (VA) and Steve Bullock (MT).  However, another letter from 15 Republican governors urged Congress to move forward with this repeal and replace bill.  Among the signatories were Matt Bevin (KY) and Paul LePage (ME).  Why is this noteworthy?  While the Governors from the states of Kentucky and Maine want Sens. Rand Paul (KY) and Susan Collins (ME) to vote in favor for the bill, the Governor from Alaska signed the letter urging Sens. Lisa Murkowski (AK) and Dan Sullivan (AK) to oppose the bill.

Stay tuned for the review of next week’s events and the impact to clinical GI.  In the meantime, ACG will continue to advocate on behalf of clinical GI and your patients.

Whitfield L. Knapple, MD, FACG

Chair, ACG Legislative and Public Policy Council