Friday, August 25, 2017

The Patient Protection and Affordable Care Act (PPACA, better known colloquially as “Obamacare”) has been a focus of repeal by the Republican Party since being passed in 2010. Repeal bills have repeatedly passed the House since the Republican Party gained a majority in 2011. President Barack Obama vetoed a repeal bill the only time legislation was passed by the Senate in 2016.  President Donald Trump promised during his election campaign that he would sign legislation to repeal PPACA and reiterated that it was a legislative priority once he was sworn into office.

The effort got off to a slow start earlier this year as the House Republican Caucus leadership had difficulty securing enough commitments to vote for HR 1628, the American Health Care Act, a bill to repeal and replace PPACA. Features of the bill include repealing the individual mandate and rolling back PPACA’s expansion of Medicaid.

As expected, all 194 Democrats in the House opposed the bill. Most of the holdouts amongst House Republicans were members of the Freedom Caucus. In an effort to gain Freedom Caucus support, House Republican leadership amended the bill to allow states to opt out of essential health benefits and allow insurance companies to charge higher premiums to people with pre-existing conditions. The House finally passed the bill by a vote of 217 to 213 on May 4. The vote was along party lines except for 20 Republicans who voted against it.

The Congressional Budget Office, Congress’ cost/benefit analysts, released its estimate (typically called a “score”) of the House-passed AHCA projecting that there would be substantial savings from enacting the bill but that roughly 23 million people would lose health care coverage by 2026. The Centers for Medicaid and Medicare Services Office of the Chief Actuary conducted its own analysis and estimated that only 13 million Americans would lose insurance coverage in that same time frame.
Senate Republican leadership had an even more difficult time than the House finding the votes to pass a repeal bill. Senate Majority Leader Mitch McConnell (R-KY) initially declared that he would hold a vote, the week of June 26 on the House-passed bill, which he renamed the Better Care Reconciliation Act, for the Senate. That week came and went but the bill didn’t have the support amongst 50 of the 52 Senate Republicans needed for passage. The challenge in getting enough support came from the holdout Republican senators demanding changes in opposite directions. Some senators wanted deeper cuts to Medicaid while others opposed cuts. Some want the individual mandate in the Patient Protection and Affordable Care Act repealed, while others didn’t (likewise on the taxes in the PPACA).

Senator McConnell introduced a revised version of the bill on July 13 and announced that a vote would be held by the end of that week. That plan changed immediately due to Senator John McCain’s (R-AZ) absence from the Senate to recuperate from surgery. McCain flew back to Washington the week of July 24 and the Senate took a series of votes on amendments, which were test votes on possible content for the final bill. Senate Majority Leader Mitch McConnell abandoned further effort to find enough votes for passage after the final amendment, which principally would have repealed the individual mandate and the requirement that employers cover their employees, failed in the early morning hours of Friday, July 28. Sen. McCain, Sen. Lisa Murkowski (R-AK) and Sen. Susan Collins (R-ME) joined all Senate Democrats in voting against the amendment.

AWHONN weighed in with concerns about the legislation to members of Congress throughout the process. AWHONN’s concerns were the proposed cuts to Medicaid, which pays for half of all child births, and the proposal to allow states to opt out of requiring insurance plans to provide the ten essential health benefits mandated by PPACA (coverage for pregnancy, maternity, and newborn care; mental health and substance use disorder services; prescription drugs [including birth control]; and pediatric services. The bill would also block Medicaid and Title X family planning funds to certain qualified providers, which could strip birth control access and preventive health care from many low-income women.

It’s not clear what will happen next for healthcare legislation. There are bipartisan efforts in both the House and Senate to craft healthcare reform legislation, both of which focus on stabilizing the private health insurance market. AWHONN will evaluate these bills when text becomes available. AWHONN monitors legislation and advocates for public policies that advance the association’s mission “to improve and promote the health of women and newborns and to strengthen the nursing profession.” You can read AWHONN’s 2017 Federal Legislative and Policy Agenda online.