http://www.politico.com/story/2017/05/04/house-health-care-bill-senate-doa-238000?cmpid=sf

After all the energy the House just expended on ramming through its Obamacare repeal, the Senate is about to start over.

“We’re writing a Senate bill and not passing the House bill,” said Sen. Lamar Alexander (R-Tenn). “We’ll take whatever good ideas we find there that meet our goals.”

They need to end up with a bill that can win over 50 of the 52 GOP senators in the narrowly divided chamber. And even if they accomplish that, their bill could be unpalatable to House conservatives. The House bill squeaked through on a 217-213 vote.

The two chambers have not coordinated much in recent weeks as the House — with an assist from the White House — frantically worked to kick the health care bill to the other side of the Capitol. Senate Republicans say they’ll take the time they need to understand the House bill’s ramifications. And they will insist on a score from the Congressional Budget Office before voting, unlike the House.

“Like y’all, I’m still waiting to see if it’s a boy or a girl,” said Sen. Lindsey Graham (R-S.C.). “Any bill that has been posted less than 24 hours, going to be debated three or four hours, not scored? Needs to be viewed with suspicion.”

http://www.commonwealthfund.org/publications/blog/2017/apr/amendment-aca-repeal-and-replace-bill?omnicid=EALERT1205401&mid=henrykotula@yahoo.com

Yesterday, House Republicans passed by a narrow 217–213 vote margin an amended version of the American Health Care Act (AHCA), their proposed repeal and replacement of the Affordable Care Act (ACA). Two amendments to the original AHCA won over members who had initially opposed the bill.

Projections of the amended bill’s effects on coverage and the federal budget are not yet available from the Congressional Budget Office. But it is still likely to significantly increase the numbers of uninsured Americans and raise the cost of insurance for many of the nation’s most-vulnerable citizens. Both the original and the new version dramatically cut and reconfigure the Medicaid program. And the latest amendments allow states to weaken consumer protections, particularly regarding preexisting conditions, while adding just $8 billion over five years to cover those with preexisting conditions who are unable to afford coverage.

What the AHCA Does

The amended bill as passed does little to change many provisions of the original AHCA including:

• a phase out of the ACA’s Medicaid expansion;
• capped federal payments to states for their Medicaid programs;
• flat premium tax credits for individual market coverage that adjust for age but not income or premiums;
• the option for insurers to charge older people as much as five times what they charge young people (instead of the ACA’s three-to-one maximum differential);
• replacement of the ACA’s individual mandate penalties with a 30 percent premium surcharge for those who fail to maintain continuous coverage;
• repeal of taxes that helped fund the ACA’s coverage provisions;
• state funding for reinsurance or other programs to stabilize the individual market.

The CBO estimated in March that the combined effects of these provisions would increase the number of people without health insurance by 24 million by 2026. Older Americans would be particularly hard hit by the bill, experiencing much higher premiums relative to the ACA and the greatest coverage losses.

What the Amendments Change

The amendments offer states the option to apply for waivers to reduce ACA consumer protections that have enabled people with health problems to buy private health insurance. Beginning in 2019, states could waive the ban on charging people with preexisting conditions higher premiums for those who do not maintain continuous coverage. But states could only do this if they set up special programs to help people with conditions like cancer or heart disease who could no longer afford coverage. States could also change the ACA’s required minimum package of health benefits for health plans sold in the individual and small-group markets.

Despite the fact the federal ban on preexisting condition exclusions would remain under the AHCA, as Tim Jost points out, insurers could reach the same end by not covering services like chemotherapy that sick people need, or by charging very high premiums for individuals with expensive, preexisting problems. In addition, waiving the ACA’s essential benefit requirement could weaken other consumer protections like bans on lifetime and annual benefit limits and caps on out-of-pocket costs.

States that allowed higher premiums for people with health problems would be required to set up programs such as high-risk pools or reinsurance for high claims costs. Or under an AHCA amendment proposed earlier in the month, states could also participate in an “invisible risk-sharing” program, a hybrid between a high-risk pool and reinsurance for high claims costs. The federal government would provide $15 billion over 2018–2026 for states to share. But while reinsurance options might protect insurers from high claims costs, giving them the ability to charge premiums based on health status would result in many people with preexisting conditions facing unaffordable premiums. As for high-risk pools, prior research has found that such pools operated by states before the ACA were expensive both for states and for people enrolled in them, and covered only a small fraction of the individuals who would have benefited. Avalere estimates that there are currently more than 2.2 million people with preexisting conditions in the individual market. The new funding of $8 billion under the amended AHCA, in addition to the previously designated $15 billion, amounts to just $3.3 billion for states to share in 2019. Assuming states used this funding for high-risk pools, it is sufficient to help only 110,000 people, or 5 percent of those with preexisting conditions. Moreover, even this group of people could have critical services excluded from their benefits if their state weakened the essential benefit package.

Looking Forward

Setting aside the amended AHCA’s potential effects on the health and health care of Americans, many questions and uncertainties remain about the bill’s timing and fate. First, the fate of the amended AHCA in the Senate remains uncertain. Some possible provisions—affecting essential health benefits, premium increases based on health, and other features—may not withstand scrutiny by the Senate parliamentarian as she evaluates whether they are appropriate parts of a budget reconciliation bill, and thus exempt from filibuster. Furthermore, many moderate Senate Republicans reportedly have concerns about the Medicaid provisions of the AHCA.

It now appears that the Senate may actually set aside the House legislation and write their own bill from scratch. The resulting bill would undoubtedly be designed to meet the requirements of the Senate reconciliation process, and thus be exempt from filibuster—something the House bill did not accomplish. Newly crafted Senate legislation might take a very different approach to the ACA’s Medicaid provisions, and even drop budget restrictions such as individual caps or block grants. Senators may also make the premium subsidies more generous to reduce the numbers of Americans who will lose private insurance under the AHCA.

From a legislative viewpoint, the greater the divergence between the House-passed and Senate-passed bills (if the Senate actually passes legislation), the more complicated it will be for House leadership to hold its fragile 217 vote majority together to pass a House–Senate compromise.

Second, the complex legislative maneuvering around the AHCA should not detract attention from the fundamental facts. Health insurance saves lives and protects Americans from crippling medical debt and even bankruptcy. Changes to existing legislation that result in fewer insured Americans will undermine the health and quality of life of millions of people, as well as increase economic inequality in this country.

http://www.medpagetoday.com/Washington-Watch/repeal-and-replace/65028?xid=fb_o_

The House of Representatives voted 217-213 here Thursday to repeal and replace the Affordable Care Act (ACA) with a plan that critics say could throw millions of people off of health insurance and cause premiums to rise steeply for older Americans.

The vote on a revised version of H.R. 1628, the American Health Care Act (AHCA), came just before House members headed out of town for a week-long recess. The measure now heads to the Senate, where many observers say it will have a tough time getting through. Reaction to the vote from the healthcare community was swift and negative, with many organizations predicting dire consequences for patients.

Under the original version of the bill, the Congressional Budget Office (CBO) estimated that 24 million people would lose their health insurance as of 2026 if the bill were passed; it would also reduce the deficit by $337 billion over the same period, CBO said. However, the current bill — which has several revisions — was voted on too quickly for the CBO to develop a revised estimate.

Mandates Eliminated

The AHCA would eliminate the taxes and mandates that financed the ACA — including the individual and employer mandate penalty — allow insurers to charge older adults and young people less, and replace subsidies based on need with flat tax credits based primarily on an age. Over time, the plan would repeal the Medicaid expansion and put a ceiling on the entitlement program by shifting its structure to a per-capita block grant, which would increase as enrollee size increases. The bill would also freeze federal funding for Planned Parenthood.

The original AHCA bill was scheduled for a vote on March 24, but it was pulled at the last minute by House Speaker Paul Ryan (R-Wisc.) after he determined he did not have enough votes to pass it. Since then, Republicans made several changes to their bill in order to attract recalcitrant members of their party, both moderates and conservatives.

These included:

• An amendment by Rep. Tom MacArthur (R-N.J.) that would allow states to opt out of requiring insurers to cover the ACA’s list of “essential health benefits”; instead, states could develop their own lists of what benefits they considered essential. The amendment also would allow states to charge more for 1 year to patients with pre-existing conditions if they have been without insurance coverage for 63 days or more. This type of medical underwriting would be done in lieu of a 30% penalty called for under the law for patients who re-enroll in health insurance after such a lapse in coverage. States who opt to allow medical underwriting also would have to set up high-risk pools for patients with high costs due to pre-existing conditions.
• An amendment by Reps. Fred Upton (R-Mich.) and Billy Long (R-Mo.) that would provide states with an extra $8 billion over 5 years to set up high-risk pools to cover patients with high costs due to pre-existing conditions, in addition to the $130 billion already in the bill that states could use for that purpose. Although no CBO estimate is available, an estimate from the Center for American Progress, a left-leaning think tank here, found that states would need an extra $200 billion for the high-risk pools to be adequately funded, assuming that 5% of patients in the individual and small-group markets end up in the pools.
• An amendment by Rep. Martha McSally (R-Ariz.) to prevent members of Congress from being exempted from the AHCA. The AHCA originally exempted Congress members from being affected by state waivers.

Rep. Phil Roe, MD (R-Tenn.), an ob.gyn., said he was voting for the bill because the ACA cannot be fixed. “The whole [ACA] plan is so complicated it’s impossible,” he told MedPage Today in a phone interview. “There are people out there who got helped by [the ACA], no question, but they’ll get helped by this bill also.”

More than half of those who have coverage through the ACA “have out-of-pocket costs and copays so high that they don’t go for healthcare,” he said. “If you have a health insurance card but you can’t use it, it’s not of much value to you. So we have to try to get the costs down.”

Medical Groups Pan the Measure

Medical groups panned the House’s action. “The bill passed by the House today will result in millions of Americans losing access to quality, affordable health insurance and those with pre-existing health conditions face the possibility of going back to the time when insurers could charge them premiums that made access to coverage out of the question,” Andrew Gurman, MD, president of the American Medical Association (AMA), said in a statement. “The AMA urges the Senate and the Administration to work with physician, patient, hospital and other provider groups to craft bipartisan solutions so all American families can access affordable and meaningful coverage.”

“The American College of Physicians (ACP) is extremely disappointed” in the bill’s passage in the House, ACP president Jack Ende, MD, said in a statement. “The House action is by no means the end of the story, however. ACP will continue to do all that it can to ensure continued coverage and access for the millions of patients who have benefited from the Affordable Care Act.”

Heated Floor Debate

Debate on the House floor was heated. “How did we get to this point?” asked Rep. Michael Burgess, MD (R-Texas), an ob/gyn. “The ACA is simply not working for the American people; it is limiting choices, it is raising costs, it is leaving millions without access to care. The ACA has left the individual market in shambles and is driving insurers away from offering coverage.”

“Pathetic — that is the word to describe this process and this bill,” said Rep. Jim McGovern (D-Mass.). “If the American people could sue Congress for malpractice, my Republican friends would be in deep trouble. How could you do this to the people you represent? You’re allowing insurance companies to discriminate against people with preexisting conditions? What is wrong with you guys?”