From the National Association of Health Underwriters Washington Update, April 28, 2017
House Republicans are continuing their efforts to pass the American Health Care Act after they were unable to hold a vote on the bill last month due to a lack of support within the caucus. An amendment introduced this week to allow states to opt out of parts of the ACA could help increase support for the package, although whether it will be enough to pass with a majority of the House remains unclear. At least 15 House Republicans have publicly stated they will still not support the bill even with the current amendment, and another two dozen are leaning no or are undecided, some of whom previously publicly supported the bill. This continues to cast doubt on the ability to reach the necessary 216 votes for passage in the lower chamber as Republicans can only afford to lose 22 votes. Late yesterday, House Republican leadership announced that after initially considering a vote this week at the White House’s request, they would postpone a vote until next week at the earliest.
As we noted last week, the amendment to allow for more state flexibility in the ACA requirements would join an earlier amendment already approved by the House Rules Committee creating a $15 billion “Federal Invisible Risk Sharing Program.” The new amendment was 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 amendment would allow states to receive a waiver from the Department of Health and Human Services to opt out of the ACA’s essential health benefits and age and community rating provisions by proposing at least one of the following: reduce average premiums for coverage, increase enrollment, stabilize the market, stabilize premiums for individuals with pre-existing conditions, and increase the choice of health plans. The waiver would be contingent on the state setting up a high-risk pool for consumers with preexisting conditions.
The amendment was a welcome change for the House Freedom Caucus, the group of the most conservative members of the Republican Party, who largely opposed the last iteration of the AHCA for failing to fully repeal the ACA. Notably, Representatives Jim Jordan (R-OH), Raul Labrador (R-ID), Dave Brat (R-VA) and Scott DesJarlais (R-TN), all who vehemently opposed the previous bill, now have publically stated they will support the bill with the amendment. The group made a tepid but official endorsement of the amendment this week, acknowledging that while the bill with the amendment still falls short of their demands, it does help to deliver on their promise to repeal key provisions of the ACA and they would work with the Senate on other ways to improve the bill. The Freedom Caucus requires that 80% of its members support a legislative item in order to garner an official endorsement.
The tradeoff to garnering the support of the Freedom Caucus and its roughly three-dozen members is that it threatens the lukewarm support of more moderate members, as well as potential support from Republicans who previously opposed the AHCA for dropping ACA coverage and consumer protections for their constituents. The Congressional Budget Office had already released a report claiming that as many as 52 million Americans would be uninsured under the AHCA, and the new amendment is likely to further increase the number of uninsured while also eroding the ACA’s consumer protections. The CBO has yet to release an updated score of the new bill with the latest amendments, and many centrist Republicans are unlikely to support the bill without a new score.
The centrist Tuesday Group, led in part by MacArthur, has not offered an endorsement of the deal brokered by its leader, and the Freedom Caucus and many of its roughly 50 members continue to express reservations about the bill and claim that negotiations are moving further away as concessions are made to the far right of the party. Among the biggest objections is over consumers with preexisting conditions, as Representative Mario Diaz-Balart (R-FL) said this week: “My concern has always been [about] what a lot of us talked about: people with pre-existing conditions, the elderly. Where is the part that is better for the folks I’m concerned about it? I’m not seeing it at this stage.”
The hesitation among centrists is in part coming on the waves of fervent opposition of many industry groups that are continuing to push hard against the bill. AARP claims that the amendment would cause premiums for the sickest patients to increase to more than $25,000 per year and the Catholic Health Association stated, “the recent amendments…are even more disastrous for people who have just gotten healthcare. This is contrary to the spirit of who we are as a nation, a giant step backward that should be resisted.” Additionally, the American Medical Association, American Hospital Association and America’s Essential Hospitals all voiced strong opposition to the bill. The AMA claimed that the amendment to the bill “could effectively make coverage completely unaffordable to people with preexisting conditions” while the AHA said that the amendment would “dramatically worsen the bill.” And health economist Craig Garthwaite noted, “This reads like another example of a policy written by people who either don’t know or don’t care about how health markets work.”
The continued outside pressure among industry groups on centrist Republicans to oppose the bill with the recent amendments continues to put into question whether House Republicans will be able to pass the AHCA out of the lower chamber and send it to the Senate for consideration, where the bill is even more in question. Both centrist Republicans and far-right members had previously expressed strong reservations about provisions of the AHCA. This includes Senators Rob Portman (R-OH), Lisa Murkowski (R-AK), Susan Collins (R-ME), Ted Cruz (R-TX), Rand Paul (R-KY), Mike Lee (R-UT), James Lankford (R-OK) and Tom Cotton (R-AR), all of whom have expressed concern either for the AHCA going too far or not far enough. There is an even narrower margin for passage in the Senate, where Republicans can only afford to lose two votes, assuming that Vice President Mike Pence would cast a tie-breaking vote.
As the negotiations continue, it is becoming increasingly clear that Republican voters are holding the Administration and Congress accountable for the future of health reform. A new poll shows that a majority of Republican voters (53%) now believe Trump and congressional Republicans are responsible for the ACA, up from just a third of respondents only two weeks ago. Fully three in four voters overall say that the president and Congress should focus on making the ACA work and they are responsible for any consequences of health reform moving forward. Previously, the president had said he would cast blame on Democrats for any of the law’s failures and would use them as leverage for passing his own priorities. But with Republicans now placing the onus on their own party, there will be more of an incentive to ensure that any reforms put forward will not cause any further harm on their constituents.