Under increasing pressure from the Trump administration to pass a budget resolution that would gut the Affordable Care Act, House Republicans appear to have reached a compromise that they contend will better address concerns about coverage for Americans with pre-existing conditions, but which critics say will ultimately do little to make sure these people aren’t left without access to affordable, quality insurance.
After the American Health Care Act — the name of the budget resolution being used by the GOP to try to undue key components of Obamacare — was stopped short of a vote when Speaker of the House Paul Ryan realized he couldn’t garner support from either hard-line conservative Republicans or more centrists members of the party, a number of revisions were made to win over enough lawmakers from both camps.
First, the AHCA was amended to allow states to opt out of a variety of current Obamacare requirements, including the provision that limits insurers’ ability to charge higher premiums based on a person’s medical history. While this would not explicitly allow insurance companies to deny coverage to people with pre-existing conditions, critics argue that it would let insurers effectively price these high-risk patients out of being able to afford coverage.
This revision may have helped to gain votes from conservative factions within the GOP, like the Freedom Caucus, but it also had the effect of alienating the more moderate Republicans, like Rep. Fred Upton of Michigan.
To address concerns about pre-existing conditions, states that leave high-risk patients in peril of being without insurance would have to set up some sort of risk-pooling or reinsurance program to make sure something is available for these people. The AHCA revisions included $130 billion (over the course of ten years) to help fund these programs, but Upton and a number of other Republicans still felt that was too little to actually do anything. In fact, Upton recently noted that throwing more money at the problem would not “do the trick.”
However, after a Wednesday morning meeting with President Trump, Upton and fellow AHCA skeptic Rep. Bill Long of Missouri appear to have converted to likely yes votes, thanks to the promise of an additional $8 billion over five years, so an average of $1.6 billion per year.
Critics of the AHCA argue that these funds are far from sufficient to provide quality, affordable health insurance is available for Americans with pre-existing conditions.
“This amendment is like slapping a band-aid on a broken bone and expecting it to heal,” says our colleague Betsy Imholz from Consumers Union. “It’s a drop in the bucket in terms of actually providing protections for the millions of people insurers consider to have preexisting conditions.”
The Center for American Progress recently estimated that the $130 billion over ten years was less than half of what is actually needed to fund these high-risk pools. In 2008, the nonpartisan Tax Policy Center calculated that a nationwide high-risk pool would require more than $1 trillion over ten years, more than seven times what the current AHCA is proposing.
Beyond the costs and budgetary needs for the government, historical data raises questions about whether high-risk pools are effective at actually providing coverage to those in need.
Prior to the Affordable Care Act, 35 states had some sort of high-risk pooling program to provide coverage for people with pre-existing conditions. According to a recent report from the Kaiser Family Foundation [PDF], there were around 225,000 people nationwide enrolled in coverage through one of these pools, representing about 2.2% of all people in those states who were not participating in a group health insurance plan (like an employee-sponsored HMO), given that some 27% of adults under the age of 65 have at least one condition that would have barred them from getting health insurance on their own.
“State pools typically excluded coverage of services associated with pre-existing conditions for a period of time and charged premiums substantially in excess of what a typical person would pay in the non-group market,” notes the Kaiser report.
This latest iteration of the AHCA could also go to a House vote without an updated report from the nonpartisan Congressional Budget Office, which is typically asked to do the math on budget resolutions before a vote is taken. The latest CBO score for the AHCA calculated that the bill would only cut $150 billion from the federal deficit (less than half of what was originally estimated) while leaving an additional 52 million Americans without health insurance by 2026.
It remains unclear if Ryan and other AHCA supporters have the 216 votes they will need to pass the bill as it now reads. Right now the number of definitive “no” votes is around 18 to 20, which is below the 22 “no”s that would be needed to reject the bill. The real gray area is the 30 or so Republicans who have yet to commit publicly to a position.
If the House does pass the repeal bill, it will pass on to the Senate. Because the AHCA is actually a budget resolution and not a traditional piece of legislation, it only needs a simple majority to make it through the Senate instead of the usual 60 votes. The GOP only holds a two-vote majority in the Senate so Republicans would effectively need a straight party-line vote to pass the AHCA.
However, some lawmakers, including Sen. Rand Paul of Kentucky, have repeatedly expressed their disdain for the legislation, saying it doesn’t go far enough in repealing Obamacare. So the AHCA would need to be revised further if it’s going to win over these wavering legislators, but of course any changes to placate that faction may push more centrist Senators into the “no” column. And any Senate revisions would need to go back to the House for reconciliation, so even if there is a vote tomorrow, this matter is far from over.