After many fits and starts, the House Republican leadership plans to put the revised bill to repeal and replace the Affordable Care Act on the floor for a vote today:
House Republican leaders said Wednesday that they plan to bring their controversial plan to revise key parts of the Affordable Care Act to a vote on Thursday, capping weeks of fits and starts in their attempt to fulfill a signature campaign promise.
The flagging Republican effort to reshape the nation’s health-care system picked up steam Wednesday as GOP leaders tried to address concerns about people with preexisting medical conditions. But independent analysts remained skeptical that the new proposal would fully address the needs of at-risk patients who receive coverage guarantees under the Affordable Care Act, underscoring the contentious nature of the Republican effort.
Republican leaders huddled in the office of House Speaker Paul D. Ryan (R-Wis.) on Wednesday evening to figure out the next steps after a whirlwind day at both ends of Pennsylvania Avenue. Several said they would hold a vote this week only if they felt certain it could pass — meaning they now think they have the votes.
Exiting the relatively brief leadership meeting, House Majority Leader Kevin McCarthy (R-Calif.) guaranteed victory. “Do we have the votes? Yes. Will we pass it? Yes,” he told reporters.
Several Republicans said a vote is expected around lunchtime on Thursday. The House Rules Committee met late Wednesday to take procedural steps in advance of the floor vote, approving final GOP adjustments to the measure.
If the bill passes, it will face a steep climb in the Senate, where widespread disagreement remains among Republicans about how to proceed on health care.
Rep. Fred Upton, an influential Republican from Michigan, introduced the amendment that was key to resolving a major sticking point this week. It provides more financial assistance — $8 billion over five years — to help people with preexisting conditions pay for medical costs. Those people are at risk of losing protections under the GOP plan, which seeks to repeal and replace major parts of the ACA.
Just a day earlier, Upton said he could not support the Republican plan because of its stance on preexisting conditions. But he sounded an optimistic note after sketching out his fix Wednesday and meeting with President Trump at the White House.
Upton said Trump called him Tuesday afternoon. The two had a “good give and take,” he said, and Trump grew “a little angry” when Upton said he could not support the bill. But eventually, he said, they came to an agreement on his amendment.
Rep. Billy Long (R-Mo.), who like Upton was against the bill earlier this week over the issue of coverage for preexisting conditions, was also in the White House meeting.
A Washington Post analysis showed 20 House Republicans either opposed to or leaning against the bill late Wednesday, and 36 more either undecided or unclear in their positions. If no Democrats support the measure, House Republicans can lose no more than 22 GOP votes to pass their bill.
Upton’s amendment was not met with resistance by the House Freedom Caucus, a key bloc of conservatives whose opposition to an earlier version of the health-care bill led GOP leaders to yank the measure.
“I don’t see any defections because of this particular amendment from our previous whip count,” said Rep. Mark Meadows (R-N.C.), the chairman of the group. Meadows and Upton both said they had been in touch.
Documents filed with the House Rules Committee showed the Upton amendment was co-sponsored by Long and four other Republicans who had been previously undecided, suggesting that the quartet would support Ryan’s bill on final passage.
Under the GOP plan, states could opt out of parts of the ACA, meaning people with preexisting conditions could be denied coverage or charged more. Such states would have to set up “high-risk pools” to absorb some of the costs.
Upton’s amendment would help some patients with expensive conditions, such as cancer or diabetes, pay premiums and out-of-pocket costs.
Some experts doubted that $8 billion was enough to aggressively address those costs over a five-year period. According to an analysis from the Kaiser Family Foundation, the temporary high-risk pool created by the ACA covered just 100,000 people; the government paid out $2 billion in subsidies to that pool in one year.
Far more people with preexisting conditions are likely to lose health coverage under the GOP health-care plan — some estimate about 5 million individuals. Depending on how many states apply for the funds, $1.6 billion a year could be spread thin.
“For subsidies to cover 68 percent of enrollees’ premium costs, as ACA tax credits do now in the individual market exchanges, the government would have to put up $32.7 billion annually,” Emily Gee, a health economist at the progressive Center for American Progress, wrote in an analysis of the plan. “Even after applying that subsidy, high-cost consumers would still owe $10,000 annually toward premiums.”
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There was also uncertainty about how the bill would be scored by the nonpartisan Congressional Budget Office, which measures how much the legislation will cost and how many people stand to lose coverage.
Republican leaders were willing to move ahead with a vote even before obtaining an updated score. Speaking on the House floor Wednesday afternoon, McCarthy brushed off a Democrat’s concerns about a new score, noting that a previous version of the bill had already been reviewed by the CBO.
The CBO projected in late March that a revised GOP health-care plan would result in 14 million more people being uninsured in 2018 than under current law. It projected the plan would slash the federal deficit by $150 billion between 2017 and 2026.
The House is slated to go on recess Thursday until May 16, which forced GOP leaders to make a quick decision about whether to try to hold a vote before leaving town.
The White House has been putting heavy pressure on Ryan to swiftly pass a health-care bill, amid fears that Republicans will lose their opportunity if the effort continues to drag out.
The announcement late yesterday that a vote will be held today on the revised version of the American Health Care Act came after weeks in which Republicans worked largely behind the scenes to come up with a bill that could satisfy both the conservatives in the caucus represented by groups such as the House Freedom Caucus and more moderate members such as the members of the Tuesday Morning Group. Conservatives objected to the original version of the bill that failed in March largely due to the fact that it retained many of the more popular provisions of the Affordable Care Act, such as the coverage guarantee for pre-existing conditions and the provisions which allowed parents to keep their children on employer-provided policies until the age of 26, among others. To address those objections, the revised AHCA will apparently allow states to opt-out of those provisions as long as they agree to participate in the “high-risk” pools that the law establishes. However, as noted above, it’s not entirely clear that the changes to insurance markets that the law will make would even give people with pre-existing conditions in states that have opted-out any real options when it comes to coverage other than high-premium, high-deductible plans that many people will find unaffordable. It was because of this that many House moderates were objecting to the revisions to the bill and either committed to voting against it or threatening to do so. To address the concerns of that group, the bill now provides an additional $8 billion to help states fund the aforementioned high-risk pools, although it isn’t at all clear that this will be anywhere near enough money to address the additional coverage costs that people with pre-existing conditions may face in states that choose to opt-out of the coverage mandate.
While nothing is official until there’s actually a majority vote in favor of the bill, it’s unlikely that House leadership would go forward with a vote unless they were fairly certain that they have the votes they need plus a few insurance votes for good measure. So, unless the bill is pulled at the last minute, which is, of course, a possibility, it looks as though the House will pass this bill today shortly before heading out of town for a recess that will last until May 16th. That recess will be interesting to watch mostly because it will be interesting to see if we get a replay of the scenes we saw earlier this year at Congressional Town Halls where constituents confronted many Republican Members of Congress over the prospect of what could happen to their health care coverage if the Republican repeal and replace bill passes.
As for the bill itself, it will move on to the Senate where prospects of passage are murky at best. For one thing, the changes that have been made to the bill have many observers questioning whether the version of the bill likely to pass the House would qualify for Senate reconciliation status that would permit Republicans to pass it with a simple majority rather than having to gain sixty votes to invoke cloture on the bill as is the case with most other legislation. If it doesn’t qualify for reconciliation, then the bill is most assuredly dead in the Senate in its present form unless there were eight Democrats willing to break with their party to invoke cloture, which seems unlikely Even if it does qualify for treatment under reconciliation, though, the prospects for the bill in the Senate don’t look good at all. Conservative Republicans such as Rand Paul, Ted Cruz, and Mike Lee have voiced many concerns about the House bill in the past, for example, and moderate Republican Senators have done the same, raising concerns not just about the pre-existing condition issue but also the impact the bill would have on states that have adopted the Medicaid expansion made available under the PPACA. Additionally, while reconciliation does do away with the sixty vote bill, it allows virtually unlimited amendments to whatever legislation the Senate is considering. Finally, there is some talk on Capitol Hill that the Senate could choose to essentially ignore the substance of the House bill and come up with its own bill. In any case, the process in the Senate is likely to take much longer than it did in the House, and likely to result in something quite different. This means that the two chambers will be required to take the matter to a Conference Committee to try to cobble together a bill that can pass both chambers, a process that will take months at least and which will likely be slowed down by the need to deal with matters ranging from the Federal Budget for the next Fiscal Year, tax reform, and what is apparently the Trump Administration’s upcoming infrastructure plan. This puts a final vote closer to the 2018 election, of course, and that means that, in the end, the fate of this effort to replace and replace the PPACA still isn’t complete.
