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House Passes AHCA To Repeal and Replace ACA By 1 Vote Margin

House republicans get narrow victory as AHCA passes with a slim majority and moves to an uncertain future in the Senate

House passes ACA repeal bill

Source: Thinkstock

By Jesse Migneault

- The House has successfully passed the American Health Care Act (AHCA) to repeal-and-replace the ACA.  This was the House GOP’s second attempt to pass the bill, after the first vote was abruptly cancelled by Speaker Paul Ryan in March for lack of support. 

The vote was 217 yae, 213 nay, passing the needed 216 by only one vote.  There was one member who did not record a vote.  Democrats voted unanimously against and were joined by 20 Republicans.  The cut off for the GOP to pass the bill was to keep 22 of its own caucus from voting against the legislation.   

Armed with a new amendment aimed at moderates and conservatives, the AHCA was rushed to a house vote the same day Congress is set to leave that evening for an eleven-day vacation. 

The hurried reintroduction of the present bill came about after continued urging by the White House and GOP leaders to make good on campaign promises to repeal or replace the ACA. 

Over bipartisan objections this bill came to a vote without a CBO review.  A previous report from the CBO stated that the AHCA could result in over 24 million Americans losing healthcare.  

READ MORE: House GOP Leaders Pull American Health Care Act Before Vote

The core of the AHCA, and the reason for its controversy, is that it threatens to remove or eliminate several popular mandates of the ACA.   Chief among those is the guaranty of affordable coverage, or coverage at all, for those with pre-existing conditions.

For those with pre-existing conditions the MacArthur amendment mandates coverage must be made available by insurers, although it does not codify what that coverage must cover, or what it would cost. 

In a letter from the AMA the organization called out the amendment's language as “illusory,” and would likely result in patients with pre-existing conditions to be priced out of the health insurance market entirely.

“As we have previously stated, we are deeply concerned that the AHCA would result in millions of Americans losing their current health insurance coverage. Nothing in the MacArthur amendment remedies the shortcomings of the underlying bill.”

Over 87 medical organizations and patient advocacy groups have sent letters to congress to express their continued opposition to the AHCA and its MacArthur amendment.  

READ MORE: Proposed ACA Replacement Moves Coverage Choices to the States

The AHCA would also change the formula for how premiums are determined based on age.  This current 3:1 ratio, would become a 5:1 ratio for premiums, with seniors being charged five times the rates of younger members. 

The AHCA would also substantially reduce premium subsidies.  This would decrease enrollment across the board, and as found in several studies force healthy mid-to-lower income individuals to leave the marketplace entirely. 

This would result in a disproportionate number of high-risk cost intensive patients with insurance.  This could drive up rates for anyone still left in the insurance pool, resulting in still more people leaving, which could continue to drive up rates.

Perhaps the most destabilizing provision in the AHCA would be the scale back, and eventual phase out of Medicaid expansion funds by 2020.   The ACA backed Medicaid expansion has resulted in millions more being insured, the bulk of the ACA membership rolls.  

The result of this expanded preventative care to lower income individuals and families has been seen to save costs in the long run, by reducing ER visits and the early treatment of chronic conditions, among other factors.

READ MORE: Why GOP Should Hold Off on Replacing the Affordable Care Act

A major component of the amendment to the AHCA presented by congressman Tom MacArthur (R-NJ) is the promotion of state waivers to get around ACA coverage requirements. 

Via state waivers payers would no longer be required to charge individuals the same premium price for the same coverage, as is currently law.   It would also allow premiums to be increased on those with pre-existing conditions if they lapsed in coverage.

Even if individuals could afford coverage the waivers would also allow states to establish their own list of essential health benefits, instead of using those mandated by the ACA.  

These essential health benefits currently include prescription drugs, preventative health and mental health, among others.  

The ACA waivers would be submitted by the states and approved by HHS.   Under the revised AHCA the state waivers would receive a default approval if not denied within 60 days by HHS.

The waivers would be in effect for ten years, unless a state ends its risk sharing program.

The MacArthur Amendment does continue to prohibit gender consideration by payers in establishing premiums, although that could be compromised under the state waiver program as well.  

The House has voted over 50 times in the last 5 years to repeal in whole or in part the ACA.  As this bill moves on to the Senate where estimates show it falls well short of a 51 vote majority, it will return to the house in an altered form essentially making today’s vote more a parliamentary exercise than a legislative accomplishment. 

As outlined in the AHCA,  federal savings garnered from Medicare/Medicaid supplement cuts, general coverage reductions and enforcement of the individual mandate would be reallocated as tax breaks for payers and the top-earners, who are required to pay an additional tax under the ACA. 


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