House Votes to Repeal and Replace the ACA

MedPage Today, May 5, 2017

The House of Representatives voted 217-213 here Thursday to repeal and replace the Affordable Care Act (ACA) with a plan that critics say could throw millions of people off of health insurance and cause premiums to rise steeply for older Americans.

WASHINGTON -- The House of Representatives voted 217-213 here Thursday to repeal and replace the Affordable Care Act (ACA) with a plan that critics say could throw millions of people off of health insurance and cause premiums to rise steeply for older Americans.

The vote on a revised version of H.R. 1628, the American Health Care Act (AHCA), came just before House members headed out of town for a week-long recess. The measure now heads to the Senate, where many observers say it will have a tough time getting through.

Under the original version of the bill, the Congressional Budget Office (CBO) estimated that 24 million people would lose their health insurance as of 2026 if the bill were passed; it would also reduce the deficit by $337 billion over the same period, CBO said. However, the current bill -- which has several revisions -- was voted on too quickly for the CBO to develop a revised estimate.

Mandates Eliminated

The AHCA would eliminate the taxes and mandates that financed the ACA -- including the individual and employer mandate penalty -- allow insurers to charge older adults and young people less, and replace subsidies based on need with flat tax credits based primarily on an age. Over time, the plan would repeal the Medicaid expansion and put a ceiling on the entitlement program by shifting its structure to a per-capita block grant, which would increase as enrollee size increases. The bill would also freeze federal funding for Planned Parenthood.

The original AHCA bill was scheduled for a vote on March 24, but it was pulled at the last minute by House Speaker Paul Ryan (R-Wisc.) after he determined he did not have enough votes to pass it. Since then, Republicans made several changes to their bill in order to attract recalcitrant members of their party, both moderates and conservatives.

These included:

  • An amendment by Rep. Tom MacArthur (R-N.J.) that would allow states to opt out of requiring insurers to cover the ACA's list of "essential health benefits"; instead, states could develop their own lists of what benefits they considered essential. The amendment also would allow states to charge more for 1 year to patients with pre-existing conditions if they have been without insurance coverage for 63 days or more. This type of medical underwriting would be done in lieu of a 30% penalty called for under the law for patients who re-enroll in health insurance after such a lapse in coverage. States who opt to allow medical underwriting also would have to set up high-risk pools for patients with high costs due to pre-existing conditions.
  • An amendment by Reps. Fred Upton (R-Mich.) and Billy Long (R-Mo.) that would provide states with an extra $8 billion over 5 years to set up high-risk pools to cover patients with high costs due to pre-existing conditions, in addition to the $130 billion already in the bill that states could use for that purpose. Although no CBO estimate is available, an estimate from the Center for American Progress, a left-leaning think tank here, found that states would need an extra $200 billion for the high-risk pools to be adequately funded, assuming that 5% of patients in the individual and small-group markets end up in the pools.
  • An amendment by Rep. Martha McSally (R-Ariz.) to prevent members of Congress from being exempted from the AHCA. The AHCA originally exempted Congress members from being affected by state waivers.
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