The Republican majority in the House was successful in passing the American Health Care Act (AHCA), its plan to repeal and replace the Affordable Care Act (ACA), by a narrow margin of 217-213 over objections about how it could affect people with pre-existing conditions and resistance from major healthcare associations.
“A lot of us have been waiting seven years to cast this vote,” House Speaker Paul Ryan said. “Many of us are here because we pledged to cast this very vote.”
Arguments on House floor were more heated than the March debate on the earlier version of the AHCA, which ended up being pulled before any vote took place. Democrats called the current version of the legislation “reckless,” “heartless” and “embarrassing,” citing how it allows states to waive required benefits like emergency and maternity care, rolls back the Medicaid expansion and opens the door for insurers to charge customers more based on their medical history if they allow coverage to lapse for more than 63 days.
The bill does maintain the ACA’s ban on insurers denying coverage based on pre-existing conditions, but to Rep. Jim McGovern, D-Massachusetts, if insurers are allowed to charge those customers more, the protection is essentially eliminated.
“To come on the floor and say it does, to try to fool people, you may get away with it in the short-term,” McGovern said, “but I’ll tell you, people will figure out soon enough when they’re denied healthcare coverage.”
Rep. Doug Gordon, R-Georgia, claimed it was Democrats who were lying and saying the AHCA does protect people with pre-existing conditions, while offering greater choice in the individual market.
“If you want the deception, follow the other side,” Gordon said.
Pre-existing conditions had been the sticking point of Republicans wavering on the bill, including House Energy and Commerce Committee Chairman, Fred Upton, who switched back to “yes” after authoring an amendment adding $8 billion in funding for Patient and State Stability Fund, some of which could be used to fund high-risk pools.
While the extra money was enough to win back moderate votes on the bill, it would, at best, cover about 600,000 of the 2.2 million individual market customers with pre-existing conditions, according to an analysis from Avalere.
“Given the amount of funding in the bill, the program can only afford a few small states to opt into medical underwriting,” said Caroline Pearson, senior vice president at Avalere. “If any large states receive a waiver, many chronically ill individuals could be left without access to insurance.”
The additional funding also failed to convince some of the Republicans voting “no,” including retiring Rep. Ileana Ros-Lehtinen of Florida, who said the risk pool funding was “inadequate,” adding the bill would make it coverage “more difficult to obtain” for older and poorer customers.
In the end, 20 Republicans voted against it, below the 22 vote threshold the caucus could afford to lose and still pass the bill. All Democrats voted “no.”
The bill’s effects go beyond the individual market to affect employer-sponsored plans, as well. As first reported by the Wall Street Journal, large employers could choose what state’s benefit regulations to follow and impose lifetime or annual caps on coverage which had been banned under the ACA.
These provisions led to almost united opposition from the healthcare industry, including groups like the American Medical Association, American Hospital Association and the American College of Emergency Physicians. Republicans largely dismissed their concerns, with Gordon claiming they’re “trying to cover up seven years of their first mistake” after supporting the ACA.
What both sides could agree on was the inevitability of the Senate making substantial changes to the bill. In that chamber, Republican can only afford to lose two votes within their caucus, with Vice President Mike Pence breaking a 50-50 tie, and at least six senators had major reservations with the last version of AHCA.
“When they send it over here, it’ll be a real big challenge on the Senate side as well, and you’ll have an opportunity to file lots of stories about the discussions as we move toward trying to achieve that,” Senate Majority Leader Mitch McConnell, R-Kentucky, told reporters earlier this week.
More will be known about the new AHCA’s impact before any Senate vote. Under the rules for budget reconciliation, a process which allows legislation to avoid any Democratic filibuster, the Senate will have to wait for the Congressional Budget Office’s (CBO) report. Its examination of the March version of the bill wasn’t kind, as it estimated 24 million people would lose their insurance coverage by 2026 if the legislation was enacted.
“When the CBO (report) comes out on this, it’s going to be even worse,” predicted House Minority Leader Nancy Pelosi, D-California.