As you’ve probably noticed, there is is a lot going on down in D.C. right now. Amid all the confirmation hearings, investigative hearings, and press events about hearings, the House of Representatives is preparing to vote on the recently unveiled replacement to the Affordable Care Act. However, the bill they consider later this week will be slightly different from what was first released.
So far the repeal-and-replace plan has been a saga in many parts, but a fast-moving one to say the least, with every step taking place just this month.
On March 2, a bill was said to exist but was literally, physically hidden from the public, the press, and many members of Congress itself, leading to one of the most bizarre Benny Hill-style treasure hunts in recent D.C. history.
A few days later, on March 6, the public finally got to see some of the text, which then had to run in one way or another through three separate House Committees — Ways and Means, Commerce, and Budget — in three separate markup hearings.
As a recap, the text that went through those committees has several provisions, including but not limited to:
- Nullifying the individual mandate: No insurance? Law don’t care. The penalty for failing to insure yourself drops to $0, significantly changing the incentives for being part of the general pool of the insured.
- Nullifying the employer mandate: Don’t want to pay for your employees to have insurance? Law don’t care. The penalty for large employers failing to offer insurance to their workers drops to $0.
- Maintains pre-existing condition ban, but with a twist: If you maintain continuous coverage, your new insurer can’t deny you coverage for having a pre-existing condition. However, if you have an insurance gap between coverage policies, it’ll cost you an extra 30% to buy insurance again.
- Health and Flex Spending Accounts: The bill proposes significant expansion of and changes to these programs, as we explained in-depth here.
- Tax credits: The bulk of the focus in the AHCA is a plan to use a new series of refundable tax credits to give individuals who don’t have access to insurance some money back that they can use to purchase insurance on their own. The initial proposed structure varies by age and by income.
Each of those three committees has since advanced a version of the AHCA — sometimes very narrowly — out of committee and to the House floor. But the bill needs to advance through both the full House and Senate and reach President Trump’s desk in the White House before it can become law, and that’s where things start to get really complicated.
Because politically, support — or the absence of it — is all over the map. Presuming it moves forward on a party-line vote, with no Democrats in support (a likely supposition), Republicans would need no more than two of their own to vote against it in the Senate, and no more than 21 in the House.
Even though the vote would need to be along party lines, though, support so far is not. The Washington Post has been keeping a tally on lawmakers who say they will support it; they won’t support it; or who will change their mind and lend support if certain changes are made before the bill becomes law.
And that’s what brings us to the present moment, and the so-called “manager’s amendments.”
House Speaker Paul Ryan submitted two packages of amendments — one basically a proofread, and the other full of substantial, meaningful edits — to the House Rules Committee late on March 20. Among the edits Ryan has proposed in order to bring members of his political party into line?
- A mysterious $75 billion: Nobody is actually sure what it does or how, and that’s not us being facetious. The money is simply being set aside and the bill will “instruct the Senate” to come up with a plan to use it in some way to help people between the ages of 50 and 64. Right now, there’s no actual plan.
- Tax repeals: The removal of taxes put in place by the ACA would be sped up dramatically. Instead of taking effect in 2018, tax cuts would take place this year, in 2017. That includes our old friend the tanning tax, as well as a host of other taxes small and large.
- Ends the Medicaid expansion: The amendments prevent new states from opting into the existing Medicaid expansion that brought coverage to families making 133% or less of the poverty limit in 32 states and D.C. Afterwards, anyone who gets in before the end of 2019 can be grandfathered in, and then it’s done.
- Medicaid block grants: Currently, money flows from the feds to the states for Medicaid administration on a percentage basis: The state spends $X on medical care for its residents, and the Federal government reimburses the state between 50% and 82% of the money based on the average per-capita income in the state. Poorer states get more funding, and the numbers are re-evaluated every three years. The AHCA proposes to change that into lump sums: Every state gets $X, and can spend it in whatever way they feel is best. After ten years, states can choose to keep the block grants or go back to per-capita funding. In practice, this means service cuts when the money runs out.
- Medicaid work requirements: The amendment allows states to impose work requirements as a condition of receiving medical assistance through Medicaid. Pregnant women; children under the age of 19; sole caretakers of children under 6; and persons under age 20 who are married and students in good standing are all exempt. Everyone else — including the disabled, senior citizens, and a whole pile of other folks who may not exactly find jobs waiting for them easily — can be subjected to it.
This is all happening very quickly; the House is scheduled to take its vote on Thursday, March 23, and once that happens sources tell Consumerist that Senate leadership plans to move on the AHCA during the following week, between March 27-31.
Because the AHCA proposal is what’s known as a reconciliation bill, there are some limits on how it can be handled procedurally. Once formally introduced in the Senate, it will get 20 hours of debate followed by an immediate series of rapid-fire votes on all the proposed amendments. At the end of that process, the Senate’s version goes back to the House for vote again, and, if it passes, becomes the version that heads up to the Oval Office and then becomes law.