UPDATE (JAN. 24, 2017 – 5:04pm)—Sen. Bill Cassidy (R-LA) and Sen. Susan Collins (R-ME) have released the first proposal for a replacement for the Affordable Care Act (ACA) titled the “Patient Freedom Act.” Read more about it here.
(JAN. 23, 2017)—Shortly after the inauguration ended on Friday, President Donald Trump signed his first executive orders. Here’s a breakdown of how they could impact the Affordable Care Act.
(JAN. 13, 2017)—The House of Representatives voted on the budget resolution today and approved it by a vote of 227 to 198. This means the House and Senate can move ahead quickly with the reconciliation vote that would officially repeal the ACA.
(JAN. 13, 2017)— Last night, the Senate took a big step forward in repealing the Patient Protection and Affordable Care Act (ACA). There are a lot of moving pieces, but we’ll take a look at what happened last night, what the next steps are, and what this means moving forward. We’ll also update this post as new events take place.
The budget resolution and reconciliation
Most legislation, including parts of the ACA, are subject to a filibuster in the Senate. This means that in order for the final vote to be held, 60 Senators must vote for the bill to move forward. However, the budget resolution, and legislation with a budgetary impact that is specifically authorized by the budget resolution, is not subject to the filibuster and can pass with a simple majority—just 51 votes to pass, or 50 votes plus the Vice President to cast the tie-breaking vote.
Last week, Senator Enzi introduced a budget resolution including repeal for many parts of the Affordable Care Act. That resolution was voted on late Wednesday night, with votes not completed until after 1:00 a.m. The resolution passed, 51-48. This does not mean that the ACA has been repealed. It does, however, pave the way to do so with another 51 votes.
When is the official repeal vote?
Repeal can happen as early as January 27, but could happen later. The House also has to accept the budget resolution and pass their reconciliation bill, but this will likely happen quickly. There are a handful of Senators who have asked for the process to be slowed down in order to craft a responsible transition, or in order to have a replacement bill ready at the same time that the ACA is repealed. In fact, Sens. Bob Corker (R-TN), Bill Cassidy (R-LA), Susan Collins (R-ME), Rob Portman (R-OH) and Lisa Murkowski (I-AK) introduced an amendment that would delay the repeal vote until at least March 3 in order to give Congress time to draft a replacement. Ultimately, however, they withdrew their amendment and the date of January 27 remains.
What would be repealed under reconciliation?
Because the official reconciliation bill has not yet been drafted, it is unclear what would be included. Here’s what we know from the 2015 reconciliation bill that was vetoed by President Obama, as well as the amendments that were voted down last night.
Prevention and Public Health Fund
The 2015 reconciliation bill eliminated the Prevention and Public Health Fund, and it’s likely to be a target with overall repeal as well. This Fund provides grants to state and local health organizations or nonprofits engaged in preventive screenings or health education. Programs receiving grants from the Prevention and Public Health Fund include anti-tobacco and anti-smoking campaigns, organizations providing breast and cervical cancer screenings, and organizations providing culturally-appropriate education on prostate and colorectal cancer screenings. The Prevention and Public Health Fund saves lives—research has shown that every 10 percent increase in funding for public health programs can reduce deaths from preventable causes by 1-7 percent. And it’s a smart use of our budget. Preventable diseases such as cancer, diabetes and heart disease cost the economy up to $1.3 trillion annually in both health costs and lost productivity—money that can be saved through prevention.
Through the ACA, federal funds were provided to states that expanded Medicaid access to all adults at or below 138 percent of the poverty line. Medicaid expansion and greater funding for the State Child Health Insurance Program (SCHIP) have provided coverage to an additional 12 million people compared to before the ACA was put into place. The ACA also requires Medicaid to cover preventive care and wellness programs that were not previously covered by the program.
The budget resolution makes it possible to cut off funding for Medicaid expansion, and there has been talk of restructuring Medicaid altogether. Because so many states with both Republican and Democratic governors have taken advantage of Medicaid expansion, there is a lot of support for this program. However, the Senate last night voted down an amendment that would have protected Medicaid and Medicare from major changes through reconciliation alone. It’s unclear what will happen to this aspect of the Affordable Care Act.
State Children’s Health Insurance Program (SCHIP)
SCHIP, also commonly called CHIP, provides insurance to children whose families fall into a gap where they make too much to qualify for Medicaid and too little to pay for quality insurance. Before the requirement that insurance cover pre-existing conditions, the CHIP program also provided insurance for children with health problems whose families could not afford insurance on the private market. While this program existed before the Affordable Care Act, the program is up for renewal soon and was included as part of the overall health care reconciliation bill. An amendment was offered to exempt CHIP from the budget resolution, but the amendment did not pass.
The individual mandates—the requirement everyone must pay for insurance or else pay a fee—and the employer mandates—that every organization employing more than 50 people must provide insurance—will likely be eliminated. The point of these mandates is to control costs by guaranteeing that there are enough healthy people on various insurance plans to make the plans workable for insurance companies and keep costs from rising too high. These have been the most unpopular provisions of the Affordable Care Act and were included in previous reconciliation bills.
Subsidies for insurance premiums
In order to live up to the “affordable” part of the Affordable Care Act, the ACA provides subsidies to those who purchase insurance on the health care exchanges. The subsidies are based on the price of the Silver—or mid-range—health care exchange plans and the recipient’s income. These have also been a point of debate around the Affordable Care Act, and can be eliminated through reconciliation. It is likely that they would get cut during a reconciliation bill, but would probably stay in place for a transition period.
Guaranteed coverage for preventive care and pre-existing conditions
Right now, the ACA guarantees that insurance policies fully cover preventive services with no cost-sharing. These services include colonoscopy, mammography, pap smears and vaccination for hepatitis B and HPV. We know that providing these services for free, with no cost-sharing, increases screening rates. However, if the Affordable Care Act is repealed, we will lose guaranteed coverage for preventive services.
A similar patient protection that’s provided is the requirement that everyone have access to insurance, and that there is guaranteed coverage even for people with pre-existing conditions. An amendment was offered on Wednesday night exempting this provision from any repeal legislation, but that amendment failed. If this provision is eliminated, then someone who has been responsible about screening and received an early cancer diagnosis could, in the future, be denied coverage because of that earlier diagnosis and his or her status as a cancer survivor.
It is not clear if these two provisions would be repealed under reconciliation, since they do not directly have a budgetary impact. However, it does appear that Congress is looking at the possibility of repealing the totality of the Affordable Care Act if they can, which would include these provisions.
What and when are the next steps?
This vote was a crucial first step, but it was not yet a repeal. Next, the House will also have to vote on a similar budget resolution. This will likely happen this week. Then, a resolution has to be crafted, and that resolution has to pass both the House and the Senate and be signed into law. There are a lot of steps, but Congress is trying to move very quickly. The final repeal vote could happen as soon as January 27, and be on President Trump’s desk by the end of the month. Many organizations, though, have expressed concern about the consequences of repealing the ACA with no replacement offered, and some members of Congress are asking for a replacement bill to be offered at the same time as well.
We’ll be keeping track of developments and will update this post as needed.