While President Donald Trump, House Speaker Paul Ryan and other key players in the U.S. House's passage of the American Health Care Act were putting on a celebratory press conference in the Rose Garden on Thursday, members of the Senate were telegraphing their intentions to slow down the process of repealing and replacing the Affordable Care Act.
The AHCA vote is politically dangerous for Republicans. It severely weakens the ACA’s protections for people with pre-existing conditions and would likely remove coverage for about 24 million people — the best guess until there is a new score from the Congressional Budget Office. It also includes a hefty tax cut for the upper class.
The AHCA could put Republicans in weak positions as the 2018 elections draw near. Liberal advocacy group Save My Care recently launched a $500,000 ad campaign this week targeting vulnerable GOP members who voted for the AHCA. Other attacks are likely to follow.
But the AHCA bill that passed the House likely won't become law without significant changes. Sen. Lamar Alexander (R-LA) posted a press release almost immediately following the passage of the House bill, stating it was the upper chamber’s plan to work with its own drafts and not use the House bill as a starting point. Senators have said they are in no rush and, as Alexander said, "will take the time to get it right."
If the AHCA ultimately passes the Senate and becomes law, it could look very different from the bill that squeaked through the House last week.
Here's what to watch as the debate unfolds in the Senate.
Sen. Bill Cassidy (R-LA) has said he wants the Senate’s bill to “pass the Jimmy Kimmel test,” a reference to the late night comedian’s tearful monologue about his son, who has a congenital heart disease. Kimmel’s plea — in which he lamented that “partisan squabbles divide us on something every decent person wants” — quickly went viral on the internet last week during debate on the AHCA.
In a last-minute amendment that converted enough moderate Republicans who were on the fence about the AHCA, Sen. Fred Upton (R-MI) added $8 billion to fund high-risk pools that would help cover people with pre-existing conditions. However, multiple health policy experts say the money is not nearly enough — and high-risk pools in general have little evidence of success.
The AHCA could have serious consequences for people with pre-existing conditions. The bill would enable states to apply for a waiver allowing insurers to charge higher rates to people with such conditions. That is not currently allowed under the ACA — some studies estimate the change would mean people with pre-existing conditions would be charged several thousand dollars more per year than they are now.
Most Americans know someone with a pre-existing condition if they don’t have one themselves. Conditions like diabetes, acne, depression and obesity are among those that would create major roadblocks for people trying to get coverage.
To get more moderates on board, the bill could be tweaked to make sure states that apply for a waiver have a plan that's more robust than just high-risk pools for people with pre-existing conditions. Without such a plan, patients with chronic conditions would be more likely to put off treatment until they require more costly emergency care. That could result in an increase in hospitals' uncompensated care and put more strain on critical access hospitals with already thin margins.
The AHCA includes an $880 billion cut to Medicaid over the next 10 years and phases out Medicaid expansion, which has gained favor even in red states as several Republican governors have implemented or tried to implement its expansion under the ACA. A quartet of them wrote to leaders in Congress that the AHCA currently “provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out and shifts significant new costs to states.”
HHS Secretary Tom Price has said the deep cuts to Medicaid would not mean coverage losses for anyone. But as multiple policy experts have pointed out, that is extremely unlikely. Key Republican senators have said throughout the repeal process they want Medicaid to stay robust. It’s a promise even Trump espoused — at least during the presidential campaign.
Medicaid expansion has been beneficial for states that have tried it. In addition to huge increases in the number of insured, there has been better access to care, better care integration and improved financial conditions for health systems. If the AHCA stays as is, states with Medicaid expansion would see those improvements wither while other states wouldn't get a chance to seek them out.
Aside from expansion issues, the massive cut to the program's budget would likely mean reduced access to care across the board and — again — higher uncompensated care costs for hospitals.
Age band ratings
The AARP, which has a powerful lobbying arm, has opposed to the AHCA largely because of changes that would allow insurers to charge older people more than younger people. This is allowed to an extent under the ACA, but the new bill would escalate the ratio from 3:1 to 5:1, in terms of how much older people pay more than younger people.
In a letter to Congress, the AARP said the move “would severely limit, not expand, access to quality, affordable healthcare.” The earlier CBO estimate on the previous iteration of AHCA found that premiums for a 64-year-old with an income of $26,000 a year could rise from $1,700 to more than $14,000.
Some senators have already said this makes the bill a no go for them. More may follow if the AARP continues to flex its muscles.
More than just policy
Amongst the numerous policy issues, there are also procedural considerations at play as the attempt to pass AHCA moves along.
For one thing, the GOP can only manage two defectors. Vice President Mike Pence is available to break a 50-50 tie, but with 52 Republicans in the Senate, that remains a thin margin. That means it will be important to see where centrists like Sen. Susan Collins of Maine and Lisa Murkowski of Alaska land on the bill.
Then there’s the process that Republicans are using to make passage of the AHCA possible. In order to make a simple majority all that is needed to pass the bill, the GOP is using budget reconciliation. But in using that process, only issues that are directly related to the federal budget will pass muster. Any parts of the AHCA that do not meet those strict guidelines, as determined by the Senate Parliamentarian, will not survive.
Hardly anyone in the healthcare industry would be exempt from the major changes that the AHCA proposes. The rate of uninsured, which was recently at a historically low rate, would increase. Those who have insurance and need health services, as well as older people who do not yet qualify for Medicare, would see higher premiums and out-of-pocket costs.
Those are just a few of the reasons that the American Medical Association, American Hospital Association and other prominent industry groups are calling on the Senate to make major changes to the bill before goes any further. Judging by the Senate GOP's thin margin for passing AHCA and the vulnerable positions that some senators find themselves in, the bill that came in from the House won't look the same when the Senate is done with it.