Q&A: Why repeal-and-replace of the ACA isn’t dead

Years of efforts by Republicans to repeal and/or repeal the Affordable Care (ACA) culminated in a dramatic early-morning defeat as three GOP senators voted against the rest of their party. Which leaves the healthcare industry wondering: What now?

The defeat of several Republican bills doesn’t mean any of those proposals won’t be discussed again, according to Julius Hobson Jr., former director of congressional affairs for the American Medical Association (AMA) who now works for law firm Polsinelli. Procedurally, the underlying bill that began debate last week—the House-passed American Health Care Act—is still alive, and by returning the bill to the Senate calendar after the July 28 vote, Senate Majority Leader Mitch McConnell, R-Kentucky, left the door open for the same proposals to be brought up again.

Hobson spoke with HealthExec about what the next steps may be for lawmakers, including the uncertainty around Democrats introducing their own plans and whether other legislative priorities for hospitals and health systems stand a chance in the aftermath of the repeal battle.

HealthExec: When we spoke after the House passed its healthcare bill, you said healthcare groups shut out by that chamber had a better chance of being heard by the Senate. But in the end, it was a very closed process. Why wasn’t the industry’s opinion considered?

Julius Hobson Jr.: It was more about the majority leaning on members to fulfill a campaign promise and the bill became less and less about the substance of healthcare policy. That made for a bad bill and you simply can’t do that.

The bill itself did do something unusual in that patient advocacy groups, provider groups and insurers were all on the same side. That’s highly unusual and it’s the kind of thing you have to work at to unite those folks. In the end, the pull of party tended to weigh more than the outside groups. (Sen. John) McCain’s vote probably saved some other members who probably wanted to vote no, but by him voting no, it enabled them to be team players.

Three bills were voted down during this process—the Better Care Reconciliation Act, the “repeal-and-delay” plan and so-called “skinny repeal.” Can we consider any of those proposals dead?

My attitude is no. I’m not one of those who says it’s dead because unless a bill is actually defeated in a roll call vote, and that did not happen in this instance—then a bill doesn’t die until the end of a Congress. Politically, it’s not (dead). Some of the tax cuts that were a part of the House-passed bill and were in drafts on the Senate side may resurface when we move to tax reform.

For hospitals and health systems, what kind of bipartisan legislation surrounding the ACA can they realistically expect to pass this year?

I’m not inclined to say some single bill might move, but we might see some fixes attached to other must-pass bills. We’re coming up on some must-pass things now, such as a continuing resolution to fund the federal government, that needs to be done by Oct. 1. We’ve got the (Children’s Health Insurance Program). We’ve got the debt limit and we’ve got some Medicare extenders that have to be dealt with by the end of the calendar year. Under those circumstances, my feeling is some pieces could show up on any of those as part of a larger package. But in terms of getting a single bill through in September or October? I don’t think so. I think feelings are going to be raw for a while.

That CHIP reauthorization needs to happen before Sept. 30. How will this impact the chances of a clean reauthorization bill?

CHIP was always going to be done. With the exception of some in the House Freedom Caucus, there seems to be a strong desire to get that done. I don’t think CHIP has a problem. It may be more of what gets attached to it which becomes a problem.

President Donald Trump’s reaction to the vote was to repeat his threat to “let Obamacare implode.” How serious do members of Congress and healthcare groups take these comments, particularly as they may relate to the cost-sharing reduction subsidies?

I think everybody takes that seriously. I wouldn’t say there’s any fear or concern from the end of Pennsylvania Avenue. I will tell you that, no matter how you look at it, Republicans do own it. They said they would repeal and replace—that hasn’t happened. If it doesn’t happen, they said they’ll let it wither and die on the vine, but there will be pressure on members of Congress as their constituents start to have issues on access to insurance. So there will be pressure to do something. What that something is and when it will happen remains to be seen.

The other part of the problem is we may still see some more insurers pull out of various markets because of the uncertainty. On the (cost-sharing reduction subsidies), we’re doing a month-to-month (approval) process. That’s just not good for long-term planning. It’s certainly not good for the kind of planning insurance companies do.

What about on the Democratic side? What do you see them proposing in terms of ACA fixes which could gain some Republican support?

That’s one of the things I’m curious about myself: What are they willing to propose? They’re in a situation where each side must give up something that’s in their Holy Grail. If you’re going to deal with bipartisanship and work together, it means compromise and everybody gives up something. Democrats need to figure out what that something is and I don’t know what they’ll do. To their credit, they were not gloating (about the Friday morning vote) and that can help the process. If they were gloating and chest-bumping, then I’d tell you right off the bat, we’re not going anywhere.

For the healthcare industry, what does this mean for its other legislative priorities outside of things which just need to be reauthorized? Is there room to move on other healthcare bills now or will this ACA repeal process make legislators shy away from any healthcare legislation for a while?

It did suck the oxygen out of the air for a while, but there’s some healthcare stuff you’ve just got to deal with, so that’s going to happen. The House Ways and Means Committee and Energy and Commerce Committee both passed a number of bipartisan bills, so I would think some of that stuff can be done because it’s not contentious. I think we may see some things move, but not right away. There will be some kind of break in August and that will allow for a cooling-off period.