The Senate — or at least, 13 Republican senators — are currently plugging away at their version of legislation to repeal and replace the Affordable Care Act.Hill-watchers say the goal is to have a vote within the next two weeks, but no drafts of the bill have circulated, no hearings have been held, and all talks are closed-door — so what do we know about the bill?
The first House attempt at a repeal bill was pulled minutes before Representatives were supposed to vote on it. But less than a week later it was back, shambling zombie-style to a narrow 217-213 approval.
After that comes the Senate’s turn. But but the politics of the AHCA are every inch as delicate a balancing act for Senate Republicans as they were for their House counterparts. The farthest-right parts of the party and their more moderately conservative peers have to agree on a wide swath of issues with very little margin for error: While the House version of the AHCA was able to pass with 20 Republican “no” votes, the Senate can only afford to lose two Republican votes at most. A 50-50 tie would be broken by Vice President Mike Pence.
However, The Hill, Politico, Vox, and others report that disparate elements among the Senate Republicans managed to agree on certain sticking points, and the plan is to vote on a draft bill before Congress breaks for a week of recess June 30.
So what do we know about it?
1. It’s probably a lot like the House bill…
Although initial reports were that the Senate was going to try to craft something measurably different from what the House came up with, more recent reports say that the two bills are actually pretty similar in substance.
The House version of the proposal suggested several major changes to health care law, including:
- Nullifying both the employer and individual mandates (requirements) to have or provide insurance
- Permitting states to opt out of requiring providers to cover the ten essential health benefits listed in the ACA
- Permitting states to opt out of requiring providers to not charge more to individuals with pre-existing conditions
Vox reports today that the plans currently under discussion in the Senate are likewise expected to end and reverse the Medicaid expansion, significantly restricting health insurance access among lower-income Americans, and would also allow health insurers to charge higher premiums to anyone with a pre-existing condition — perhaps as many as 131 million Americans.
…and just as secretive.
No, we’re not likely to see another literal chase around Capitol Hill looking for the text, like we saw with the Yakety-Sax-style quest for the House bill. But the process behind crafting a bill is just as opaque this time around — or perhaps even more so.
Folks in the know in D.C. tell Axios that a draft of the bill is expected to be finished as soon as this evening, when it will then be sent to the nonpartisan Congressional Budget Office for scoring.
When asked if a version of the draft bill would be made available to the public, a senior Republican aide rebuffed the idea, telling Axios, “We aren’t stupid.”
One challenge Axios’ sources cited: The plan still in constant progress, and apparently will be up until a vote is held sometime before Congress goes to recess during the week of July 3.
There also will be no committee hearings or markup sessions for the bill, which is a significant departure from ordinary Congressional procedures.
Missouri Senator Claire McCaskill, a member of the Finance Committee, challenged committee chairman Sen. Orrin Hatch over the lack of transparency and hearings.
“We have no idea what is being proposed. There’s a group of guys in a backroom somewhere making these decisions. There were no hearings in the House,” McCaskill said. “We are now so far from regular order, new members don’t even know what it looks like.”
2. It still guts Essential Health Benefits.
The Senate bill is reportedly not permitting states to let insurers increase rates on anyone with a pre-existing condition. However, like the House bill, the Senate proposal is believed to permit states to opt out of requiring insurers within their borders to cover ten areas of essential health benefits with every plan.
Those benefits are very clearly defined under current law and include:
- ambulatory patient services
- emergency services
- maternity and newborn care
- mental health and substance use disorder services including behavioral health treatment
- prescription drugs
- rehabilitative and habilitative services and devices
- laboratory services
- preventive and wellness services and chronic disease management
- pediatric services, including oral and vision care
The idea behind letting insurers sell plans that don’t cover those services is that the premiums you pay for those plans would be lower, thus resulting in lower costs to both consumer and insurer.
Except the problem is that those ten areas, among them, cover the vast majority of uses for health care. And if you suddenly find yourself needing services that your plan doesn’t cover, you’re up a metaphorical creek.
You may pay significantly less for a plan that doesn’t cover emergency services, but then owe a six-figure bill after your car is hit by a drunk driver. You may pay significantly less for a plan that doesn’t cover prenatal services, but then end up unexpectedly pregnant. Or you may pay significantly less for a bill that doesn’t cover hospitalization or chronic disease management, only to find yourself with a surprise diagnosis of a genetic disorder, cancer, or some other disease one day.
Prior to the ACA, folks who had a plan that didn’t cover anything either didn’t seek treatment when they needed to or, frequently, literally went bankrupt when they did. Our colleagues at Consumer Reports have found that requiring more people to have insurance, and requiring that insurance to cover more things, led to a huge decrease in personal bankruptcies over the past few years.
This doesn’t just affect people who live in states that opt-out, either. The nonpartisan Center on Budget and Policy Priorities points out that if even one state decides to wave the EHB requirement, then even employer-based plans nationwide could go back to imposing lifetime and annual limits on coverage.
That’s because the ACA’s ban on lifetime and annual limits for coverage only applies to essential health benefits, the CBPP notes, and employers would be free to decide which state’s definition of “essential health benefits” they want to adopt.
Got childhood cancer? Surprise! You can’t afford any more health care after age 14.
3. It still guts Medicaid.
Medicaid covers roughly 70 million low-income and disabled Americans, including elderly nursing home residents, according to the Associated Press.
The Kaiser Family Foundation breaks down that 47.5 million Americans are already over age 65, and they — and the rest of us — are going to keep aging. To that, KFF adds that currently Medicaid accounts for 53% of all U.S. spending on long-term care like nursing homes or health aides for the elderly.
So changes to Medicaid have big ramifications, from children’s health care to elder care for seniors.
The House bill proposed a number of significant changes to Medicaid, including ending the expansion; changing funding from per-capita percentage to a block grant; and allowing states to impose work requirements for receiving access to health care.
As best we know, the Senate bill hits Medicaid in two key ways: It both reverses the ACA’s Medicare expansion, and also limits funding.
The Senate Republicans have not been fighting over whether or not to cut the Medicaid expansion but, rather, how quickly or slowly to do it. Some are fine with the House’s three-year plan to end it (in 2020); others are asking for seven years to phase it out.
But as Vox’s Sarah Kliff notes: “At the end of the day, though, phasing out Medicaid expansion over seven years has the same effect as three years: You end coverage for millions of low-income Americans.”
It’s unclear as yet whether certain other provisions, like wanting any “able-bodied” person to be ineligible for Medicaid, have made it into the draft.