Congress comes back to town this week after a two week holiday. During this period of relative quiet, some of you may have forgotten exactly where we left things. Recall the proceedings on the American Health Care Act of 2017 were suspended March 24. No one was too happy with that result so a little work actually got done these last few weeks.
If you don’t have it, here is a little clip and save chart of the AHCA provisions, updated with all approved amendments:
The major changes and events since March 24 are:
- Shortly before Congress went home for the Easter and Passover holidays, they approved an amendment to the American Health Care Act of 2017 that creates a $15 billion Federal Invisible Risk Sharing Program for years 2018 through 2026. This fund is in addition to the $100 billion Patient and State Stability Fund included in the AHCA. The details on how this money will be spent are limited but generally the idea is that this money can be used to mitigate the costs of insuring very expensive individuals
- Moderate Tuesday Group member Rep. Tom MacArthur circulated a framework for additional changes to the AHCA last week that appear to have the support of at least some members of the conservative Freedom Caucus. There is no legislative language as of now – rumor has it that House leadership and Senate Budget are working on it – but the major points are:
- Reinstate Essential Health Benefits as the federal standard
- Maintain the following provisions of the ACA: prohibition on denying coverage due to pre-existing conditions, prohibition on discrimination based on gender, guaranteed issue of coverage to all applicants, guaranteed renewability of coverage, coverage of dependents up to age 26, community rating with limited waivers
- Creates a limited waiver option for states to opt out of certain ACA regulations including Essential Health Benefits, community rating rules except for gender, age (except for reductions of the 5:1 age ratio), health status (unless state has established high risk pool or is participating in a federal high risk pool.)
- To qualify for a waiver, states must attests that the purpose is to reduce premium costs, increase the number of insured or advance another public interest.
- Conservative groups like Heritage Action and Club for Growth and the ubiquitous Koch brothers have signaled that they are willing to cool it on their hunt for repeal perfection. Word on the street is that they would accept something akin to the aforementioned Tuesday Group-Freedom Caucus compromise being circulated.
- No word on changes to Medicaid suggesting that the real objections to the AHCA were primarily related to the individual market
The revival of AHCA proves once again that in politics the most important ability is reliability. After years of promising to repeal the ACA, House conservatives and their fellow travelers who were the architects of 60 plus repeal votes found themselves in an uncomfortable position with the president and their own constituencies when perfect became the enemy of the good.
The White House wants a vote this week or maybe next. House leadership isn’t publishing a timeline and will bring the bill to a vote when they have 216 of them. Our best guess right now is the second week in May will see a House vote. Don’t look for the Senate to act until July or August.
As we have done since last fall, we remind you that what Congress is attempting to accomplish with the AHCA can largely be done through regulation. That fact is even more salient if you consider the Tuesday Group-Freedom Caucus framework. Certainly a regulatory response will take longer and have a less certain result, but the fact remains that Section 1332 of the ACA and Section 1115 of the Social Security Act provide HHS with a lot of discretion to implement a reform agenda. Something to think about next time there is a legislative relief rally.
But, wait! There’s more.
When Congress returns tomorrow, it will need to extend funding of the government which expires April 29. The Freedom Caucus and other conservative groups have promised to stand down on issues like defunding sanctuary cities and Planned Parenthood. However, Democrats are demanding that Congress make permanent and mandatory payments to insurers under the cost-sharing reduction program.
So, the shutdown shoe is on the other foot.
If the idea of making the CSR payments a political football is designed to ensure greater plan participation in 2018, we must conclude that House and Senate Democrats have never met an insurance executive. True to form and in response to Democrats demands, Trump announced that for every dollar to fund the construction of a border wall, he would agree to a dollar for CSR payments. Voila! Health insurance and immigration are joined in the debate.
The betting money thinks that Republicans will agree to a one year appropriation of CSR payments as a compromise. Even easier, the Trump administration could ask for additional delays beyond the next scheduled court date of May 22 while they continue to pursue legislative solutions and make CSR payments as they have since January.
Expect a short CR this week to buy a little more time on funding the government with the major decisions coming next week.
Call with questions and we will try to answer them.
Emily Evans
Managing Director
Health Policy
@HedgeyeEEvans
