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This page was last updated on March 24, 2017.

Before the final vote on the American Health Care Act (AHCA), House Republicans have submitted numerous changes to the bill to garner more support from each ideological end of their caucus (moderates and conservatives). The amendments included some key provisions to lock down the support from other House members.

On Wednesday night, the Rules Committee voted and approved the “same-day” rule, which allows the Rules Committee to finish work on the healthcare bill on Thursday and let the House pass the rule and the bill itself, all on one day. Early this morning, the House has debated on passing the “same-day” rule and later that day the House voted and approved the “same-day” rule. By passing this rule, the changes in the bill that were made during the day on Thursday were automatically added to the bill.

President Trump met with the Freedom Caucus Thursday morning to get support for the bill. The outcome of that meeting allowed for an additional amendment to the AHCA to sway more votes in the GOPs favor. The amendment to the healthcare bill would trim the Affordable Care Act’s insurance regulation and its essential benefits requirement. By repealing the essential benefits requirement at the federal level, would allow plans on the exchange an opportunity not to provide a minimum package of essential benefits to individuals. Instead, the states would be directed to create their own standards for essential benefits for individuals who buy their own coverage. Previously the House was under the impression they could not roll back the provisions of the essential health benefits requirement under the reconciliation process, but the House obtained “new information” that the House could revise this provision under the Byrd rule.

The additional key changes of the AHCA are mentioned here.

One key change is moving up the date of the Affordable Care Act taxes repeal which help fund the credits on everything related to healthcare. This date was moved up from 2018 to 2017.

Another amendment would give states the option to require able-bodied Medicaid recipients to work, participate in job training programs, or do community services. This would allow the states to have the flexibility to create the work requirements for nondisabled individuals. Additionally, states would receive an increase in federal assistance if they implement these requirements by 5%. However, this provision would still make it harder for low-income Americans to get needed health care

Furthermore, another addition to the bill includes that states can opt to receive federal Medicaid funding as block grants for the adults and children in their program instead forcing states to shift the funding for Medicaid expansion to per capital block grants. This addition to the bill would allow for states to receive a set amount of money per enrollee, known as a per capita cap system. Under this block grant system, states would receive a fixed amount of federal funding each year, regardless of how many participants are in the program. This would reduce federal support and give the states flexibility to administer their Medicaid program

The House bill added another provision that will allow the Senate to increase tax credits for older Americans, which then will provide older Americans between the ages of 50 to 64 more assistance. This relief for older Americans would come in a form of a $75 billion\ pool of additional tax credits to help people buy policies on the individual market, but this exact provision did not appear in the actual amendment. Thus, this responsibility would land on the Senate’s lap and it might not be guaranteed. Furthermore, the Congressional Budget Office will not be able to re-evaluate the plan and administer a new “score,” which does not allow the lawmakers an opportunity to consider whether this provision may make the legislation more costly

There is a state specific amendment for New York that allows the counties in New York to keep hundreds of millions of dollars of local tax revenue that they forward to the state government to fund Medicaid programs

As of Friday afternoon, the House continued to debate on the AHCA. The House needed to receive 216 votes for the bill to advance to the Senate. Currently, there are not enough votes for this bill to pass in the House. Groups such as the Freedom Caucus, Heritage Action and Americans for Prosperity are key groups that opposes the current version of the AHCA. Later in the afternoon the House pulled the vote of AHCA.

Speaker of the House, Paul Ryan spoke during a press conference Friday afternoon to address the future of healthcare. Speaker Ryan was not able to give a clear answer on when the House will return and tackle the issue of repealing and replacing the Affordable Care Act (ACA). He stated that the ACA will stay the law of the land until the House can come together and figure out the next steps. Therefore, for the foreseeable future it sounds like the House will move on to other agenda items that the President mentioned on the campaign trail. HFA will continue to keep a close eye on what happens to the ACA and will continue to update the community.

Thank you all who have participated in our Action Alerts in the last couple of weeks. Your voice was heard!

On Monday, March 6, 2017, the Republican leadership in the US House of Representatives unveiled its long-awaited legislation to repeal and replace the Affordable Care Act. The new bill (the “American Health Care Act,” or AHCA) was rushed to simultaneous markups in the House Energy and Commerce and House Ways and Means committees on March 8, 2017, even though the bill’s overall cost impacts hadn’t yet been “scored” by the Congressional Budget Office. The bill was approved by both committees on party-line votes on March 9, 2017, following all-night sessions.

At this date, it is still very hard to predict the likely fate of the bill. The bill has drawn immediate opposition not just from Congressional Democrats but also from national membership organizations (e.g., the AARP, American Medical Association, and various hospital associations); from right-leaning as well as left-leaning health policy experts; and from Republicans at each ideological end of their caucus (moderates and conservatives). Nonetheless, House and Senate leadership say they intend to move the bill rapidly through Congress.

The AHCA threatens health care coverage for people with bleeding disorders who rely on Medicaid, or who count on being able to purchase insurance in the individual (non-group) market.

For more information about the AHCA, please keep reading. We summarize some of the bill’s key provisions below.

The AHCA would make sweeping changes to Medicaid. The Affordable Care Act (ACA) allowed states to expand their Medicaid programs to cover adults who previously didn’t qualify for Medicaid. The ACA also provided extra federal funding to support this expansion. Thirty-one states and the District of Columbia expanded their Medicaid programs pursuant to the ACA’s authority, resulting in new health coverage for more than 11 million Americans.

The AHCA would effectively repeal the ACA’s Medicaid expansion, effective January 1, 2020. The bill would keep federal funding at the higher ACA rate for people who were in the expansion population before 2020, but only if those individuals don’t at any point lose their Medicaid eligibility for a period of one month or more. The federal funding rate would decrease for all other Medicaid enrollees.

The AHCA would also make other far-reaching structural changes to Medicaid. With the enactment of the Medicaid law 50+ years ago, the federal government made an open-ended commitment to cover a set share of states’ Medicaid costs: if a state’s needs rise, so too did the federal financial contribution. The AHCA seeks to end that federal commitment to Medicaid, instead implementing a capped “per capita allotment” funding formula. Under the AHCA’s per capita cap, federal funding would erode over time (federal monies wouldn’t rise to meet, e.g., higher health costs associated with natural disasters, epidemics, and/or breakthrough treatments). The result would be a massive shift of risks and costs from the federal government to the states. States facing reduced federal funding levels would have to cut the number of people eligible for coverage, the scope of benefits covered, and/or payments made to healthcare providers who care for Medicaid beneficiaries. Since thirty percent of the bleeding disorders community relies on Medicaid, the AHCA’s proposed changes could dramatically impact access to care for these community members.

The AHCA’s changes would result in fewer people obtaining insurance on the individual market; that insurance would cost more for low- and middle-income consumers. The AHCA would replace the ACA’s insurance subsidies (premium tax credits plus cost sharing subsidies) with a system of refundable tax credits. First, the AHCA would completely eliminate the cost sharing subsidies contained in the ACA: these are critical provisions that lowered the actual out-of-pocket costs of lower income individuals.

Second, the AHCA would provide much skimpier premium tax credits than those contained in the ACA. While the ACA’s premium subsidies take into account the recipients’ income and cost of insurance (so individuals don’t have to pay more than a certain percentage of their income for their health coverage), the AHCA’s tax credits vary only with age. A middle-income 30-year-old living in Indiana, where insurance is relatively inexpensive, would receive the same size tax credit as a low-income 30-year-old living in (extremely high-cost) Alaska.

The AHCA also allows insurers to charge older people much higher premiums. The ACA allowed insurers to charge older customers more, but only three times as much as they charge younger people. The AHCA would allow insurers to charge older people five times as much (even though their premium tax credit would only be twice as high as the younger person’s).

The AHCA in its current form does not propose to undo certain important patient protections contained in the ACA. The AHCA would not repeal certain key consumer protections important to our community: the ban on lifetime and annual caps; the requirement that plans limit annual out-of-pocket spending; the requirement that plans offer family coverage to children up to age 26; the requirement that plans cover certain categories of “essential health benefits;” the ban on coverage denials and/or exclusions for pre-existing conditions; and the prohibition against medical underwriting (charging higher premiums based on health status).

Next steps. Congressional leadership intends to pass the AHCA pursuant to a “budget reconciliation” process. Under the leadership’s plan, the bill would pass the House and then go to the Senate, where it could pass with a simple majority vote (rather than the 604-vote margin needed to overcome a filibuster) – or where the bill could, as we must advocate for, go down to defeat.

The rules governing budget reconciliation limit what the AHCA can address. Basically, a law passed pursuant to this process can only affect matters related to the federal budget (this is why the bill cannot repeal the ACA’s non-budget-related patient protections). But Congressional leadership has announced that House committees are already working on bills for the next phase of their ACA repeal effort, and those bills may be introduced the same week that the AHCA goes to the House floor. We in the bleeding disorders community must remain vigilant and engaged as the legislative process continues.

Assisting and Advocating for the Bleeding Disorders Community