Following their two-week recess, Congress is set to return on Tuesday and will possibly hold a vote on the American Health Care Act (AHCA) as soon as Wednesday. After a push from the Trump Administration to hold a vote on the bill before the president’s 100th day in office (April 30th), House Republicans have been working to find an agreement within their party to be able to bring the ACHA for consideration again following decision last month to scrap the vote on the bill. An amendment this week could help win support from several “no” votes, but it is unclear if it will be enough to pass the chamber ahead of this week’s deadline. And while House Republicans work on this deal, they must also face a tighter deadline to avoid a government shutdown on Friday.
The new text of the bill has not yet been released, but is expected to include an amendment to the AHCA worked out between Representatives Tom MacArthur (R-NJ) and Mark Meadows (R-NC), who lead the centrist Tuesday Group and far-right Freedom Caucus, respectively. The AHCA currently strips out the ACA’s essential health benefits, but this amendment would reinstate them as a measure to win support from centrist Republicans. And in an effort to win support from far-right Republicans, the amendment would grants states waivers to create their own essential health benefits and allow insurers to charge consumers with pre-existing conditions higher premiums, contingent on the state setting up a high-risk pool for these consumers.
Before the AHCA was pulled from a vote last month, there were upwards of 50 House Republicans who were voicing opposition to the law or strong reservations about voting for it for a myriad of reasons. However, it is not clear whether this amendment or the amendment creating a $15 billion “Federal Invisible Risk Sharing Program” will be enough to win support of enough House Republicans to be able to reach the necessary 216 votes for passage. With 238 Republicans in the House, Republicans can only afford to lose 22 votes for the bill to pass the lower chamber. And assuming that it passes the House, it will still need to make its way through the Senate, where it can only afford to lose two votes, while as many as six Republican senators have expressed reservations over the bill.
Representative Meadows claims that the new amendment will bring along as many as two-dozen members of the Freedom Caucus. But many members of both the Freedom Caucus and Tuesday Group have said the amendments don’t address the things they had concerns about, they weren’t part of negotiations on these amendments, and neither Meadows nor MacArthur got approval of the changes from their groups before agreeing to the deal. Further, these amendments had previously been rejected by Republicans in the lead-up to the AHCA last month.
While House Republicans continue working on negotiations ahead of a White House imposed deadline to hold a vote this week, they must also contend with another more pressing deadline of keeping the government funded. Without legislation to keep the government open or a short-term stop-gap, government funding is set to expire next Friday. And after the government shutdown of 2013 when Democrats held the Senate and White House and both parties faced blame for the shutdown, now that Republicans control both chambers of Congress and the White House, the pressure falls entirely on them.
In recent years, Republicans in the House have largely been unable to win support from enough of their members to pass a continuing resolution (CR) without the support of Democrats. There are several key points of disagreement that currently threaten the passage of the current spending bill: funding for a border wall, preventing federal funds from going to “sanctuary cities,” additional defense spending, benefits for coal miners, and funding for the ACA’s cost-sharing reduction (CSR) program.
As we noted last week, the CSR program is being considered in negotiations by both parties and both are hoping to use the program as leverage in their negotiations. The Trump Administration is currently defending a lawsuit by House Republicans that the subsidies, which help offset out-of-pocket expenses for silver-tiered plans purchased through the marketplaces for households with incomes up to 250% of the federal poverty level, are illegal. And they have until May 22 to determine if they will continue to defend the lawsuit. If not, then the payments made by the government to insurers would cease, while insurers would still be required to provide the subsidy amounts owed to individuals—an amount of roughly $7 billion annually across all insurers. This could result in many insurers opting to immediately withdraw from the marketplaces and leaving millions without coverage.
Democrats are threatening to withhold support of the spending bills, and thereby jeopardizing a government shutdown, if funds for the CSR program are not included in the spending bills. Yesterday, Director of the Office of Management and Budget Mike Mulvaney indicated that the White House is willing to negotiate on funding the subsidies in a spending package if Democrats will go along with several of the White House’s legislative priorities, such as increased defense spending and border security funding.
Earlier this week, a group of health insurance officials met with Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma to discuss the subsidies. The group reported that they didn’t get clarity from Verma that CMS would continue to fund the CSR program, with Verma noting that she doesn’t have the power to make the decision. America’s Health Insurance Plans led the meeting and was joined by the Blue Cross Blue Shield Association and several large regional health plans, including Molina Healthcare, Geisinger Health Plan, Oscar Insurance Company, Kaiser Permanente and Health Care Service Corp.
As negotiations continue on both the AHCA and legislation to avoid a government shutdown, NAHU will continue to advocate for legislation and regulation to stabilize both the individual and employer-sponsored health insurance market for the coming years. This includes working to make changes to the parts of the ACA for which we are able to get consensus on a bipartisan basis, such as permanent repeals (or short of that, continued delays) of the Cadillac/excise Tax and the Health Insurance Tax (HIT). We will also continue to work with Health and Human Services Secretary Tom Price to improve market stability through regulations, and with our state chapters to pursue 1332 Waivers for the states.