Waiving ACA provisions brings mixed signals on whether repeal vote is coming

Republicans in Congress are under pressure from President Donald Trump to quickly push forward on a bill to repeal and replace the Affordable Care Act (ACA), according to multiple news sources, but for each comment saying the majority party is close to an agreement, there seems to be another denying it.

During an April 20 press conference, Trump himself predicted healthcare legislation would pass “next week or shortly thereafter.” Rather than an entirely new bill, it would be a modified version of the American Health Care Act (AHCA), the legislation that was scheduled for a vote in March and then pulled when it became clear Republicans didn’t have enough votes to pass it out of the House.

The new version would include amendments agreed to by Rep. Tom MacArthur, R-New Jersey, head of the moderate Tuesday Group, and Rep. Mark Meadows, R-North Carolina, head of the conservative House Freedom Caucus.

It maintains ACA changes to the insurance market like guaranteed issue and renewability requirements, coverage of children on their parents’ plans until they turn 26, and the prohibitions on discrimination for pre-existing conditions and gender.

The changes would include reinstatement of the 10 “essential health benefits” insurers are required to cover, which the Freedom Caucus had wanted eliminated as part of the AHCA. However, those benefits could be rolled back in individual states, as the amendments would allow “limited waivers” from federal insurance standards. That would open the door to putting people with pre-existing conditions into high-risk pools, a return to health status underwriting and even waiving some of the benefits the amendments claim to protect.

“It could allow insurers to eliminate benefits mandated under the ACA that were often omitted in the individual market prior to the ACA, such as maternity or mental health benefits,” wrote Health Affairs blogger Timothy Jost. “It could alternatively allow states to simply permit thinner coverage of mandated categories, perhaps requiring coverage for fewer drugs. But it would mean taking coverage away from people that they now have a right to.”

That approach may mean less support from moderate Republicans, negating any gains from Freedom Caucus members flipping to “yes” on the bill. Timing is also an issue, as Congress is coming back after a two-week recess and will have just days to pass a continuing resolution to avoid a federal government shutdown.

“The question is whether it can get 216 votes in the House, and the answer isn't clear at this time,” a senior Republican aide said to POLITICO. “There is no legislative text and therefore no agreement to do a whip count on.”

The amendments would almost certainly gain no support from Democrats, either.

“I’m not sure how they do this,” Rep. Ted Lieu, D-California, said to the Los Angeles Times. “Everyone knows it’s just going to die in the Senate. Really, this is all about face-saving.”

The healthcare talks could be complicated by the demands of Trump’s budget director, Mike Mulvaney. In an interview with the Associated Press, he indicated White House support for funding the ACA’s cost-sharing reduction subsidies for insurers could be contingent on Democrats agreeing to fund Trump’s wall along the Mexican border.