The House of Representatives voted 217 to 213 to pass the American Health Care Act (AHCA) moving Congress just one house away from replacing the ACA with a Medicaid block grant, reducing the essential health benefits (including mental health and substance use treatment), and weakened guarantees for people with pre-existing health care conditions.  All but 20 Republicans voted for it (217 to 213) with all 193 Democrats voting no.

The tide turned toward passage when Congressman Fred Upton (R-MI) and Congressman Billy Long (R-MO) early in the week proclaimed their opposition surprising both the White House and Congressional leadership but when they reversed course by mid-week all but the 20 Republicans moved toward passage.

Upton had objected to a compromise package negotiated by House Freedom Caucus Chairman Mark Meadows (R-NC) and Tuesday Group Co-Chair Tom MacArthur (R-NJ) because he felt it would weaken the ACA’s requirement that people with pre-existing health conditions be able to get health insurance—a major part of the ACA changes.  But later in the week after a White House meeting Congressman Upton flipped positions after new money was added to be given to states to pay for high risk pools that people could get thrown into if they are denied coverage by an insurer.  The amount added was $8 billion spread over five years.  Total health care spending is approximately $3.3 trillion per year.  The latest AHCA costs and its insurance coverage figures have not yet been evaluated by the Congressional Budget Office (CBO). The earlier evaluation showed 24 million people losing coverage but saving nearly $900 billion through cuts to Medicaid.

It is unclear what the additional $8 billion will get. Many analysts doubt that $8 billion is enough money and in fact Congressman Upton—one-time chair of the key health insurance committee, House Energy and Commerce—said Wednesday that he doesn’t know what the correct amount is, “Is it enough money? I don’t know. That’s the question that I asked and was led to believe that $5 billion would be enough, which is why it’s $8 billion.”

The modifications negotiated was enough to get the Freedom Caucus on board.  The amendments to the AHCA, allow states to opt out of ACA requirements on essential health benefits and community rating requirements (including how much older Americans are charged for coverage).  To receive a waiver of the law through HHS states would indicate that their efforts would: reduce average premiums for coverage; increase enrollment; stabilize the market; stabilize premiums for individuals with pre-existing conditions; or increase the choice of health plans.  In a new twist, the waiver becomes automatic unless HHS rejects it, a reversal of current waivers requirements.  Based on the waiver, states would set up a high-risk pool, presumably to push back on criticisms that the Majority-party plan would harm the sickest patients.

The threat to coverage and patient protection is that the waivers could accomplish some goals such as expanded markets and lower premiums by reducing requirements and standards on insurers and policy coverage and in the end, leave a patient more vulnerable.

States could opt out of the essential benefits package that include such items as maternity coverage, emergency room services, mental health and substance use coverage.  It also allows states to opt out of the community rating protections which limit insurance policies from charging patients with certain health and pre-existing condition more for their coverage.

One of the most popular provisions of the ACA is that it bans insurance companies from denying health coverage because an individual has a health condition or preexisting condition.  The President has said on many occasions he will keep that provision.  From the start, Congressional Republicans say that high risk pools for people unable to buy insurance on the market are the solution.  The problem is that high risk pools have not worked. The Commonwealth Fund has written on why they don’t work.  In their past analysis based on the experience of several state attempts, high risk pools can require premiums sometimes 250 percent higher than the individual insurance market and still require annual deductibles of $25,000 per year.  Pre-existing conditions can be whatever the company decides it is, it could be a chronic condition such as heart disease but it could be something as basic as a one-time illnesses.

Beyond the new provisions and state opt-outs, the legislation still includes the same repeal parts and it still cuts Medicaid by nearly $900 billion.  CBO has not reviewed the bill for an updated budget score or analysis of what it would do to the 24 million that would lose coverage under the original bill.  They also do not expect to have a new budget score this week.

CWLA continues to oppose the bill and will work in the Senate to reject it and instead seek to strengthen the ACA and will seek to block any block grant of Medicaid.