House Narrowly Passes Republican Health Care Bill

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What's in the bill, and how will it affect state and local governments?

On a narrow 217-213 margin, the U.S. House of Representatives on Thursday voted to approve the American Health Care Act. The legislation, which will now go to the GOP-controlled U.S. Senate, has changed a lot since the Republican lawmakers initially introduced, and later withdrew, a health care reform package in March.

The MacArthur Amendment

One major change to the American Health Care Act came in the form of a proposal from moderate Republican U.S. Rep. Tom MacArthur. MacArthur struck a deal with the House Freedom Caucus, which had stymied the March vote in part because its members objected to provisions within the bill that dealt with coverage for patients with pre-existing conditions.

Under the MacArthur amendment, states would be able to apply for waivers that would allow them to opt out of regulations that keep people with pre-existing conditions from being charged higher prices for coverage on the individual market.

According to analysis by the Kaiser Family Foundation, an estimated 52 million adults have pre-existing conditions, although most of those people would be covered through an employer plan.

States that do opt out, would be required to set up “high-risk pools” to help cover those individuals with pre-existing conditions. But these mechanisms have a checkered past. In a statement released Wednesday, Andrew W. Gurman, the president of the American Medical Association had this to say about them:  

“High-risk pools are not a new idea. Prior to the enactment of the Affordable Care Act, 35 states operated high-risk pools, and they were not a panacea for Americans with pre-existing medical conditions. The history of high-risk pools demonstrates that Americans with pre-existing conditions will be stuck in second-class health care coverage – if they are able to obtain coverage at all.”

Although the MacArthur amendment was able to secure increased Freedom Caucus support for the bill, many moderate Republicans in the House balked at the minimized protections for patients with pre-existing conditions and the lack of adequate funding for the high-risk pools those patients might be relegated to.  

The most recent amendment, proposed by U.S. Rep. Fred Upton, a moderate Republican from Michigan, was meant to alleviate some of those concerns.

The Upton Amendment

Upton, in a visit to the White House on Wednesday, proposed a change to the AHCA that would provide $8 billion in federal funding over the next five years to stabilize high-risk pools.

Many experts, however, contend that the additional funding in the amendment is far less than what may be required to make high-risk pools an affordable option for those with pre-existing conditions, some of whom require very expensive care.

While the Upton and MacArthur amendments may have brought more GOP members on board with the AHCA, questions remain, even in the House, about the degree to which states will take advantage of these amendments.

According to The New York Times, U.S. Rep. Joe L. Barton, a Texas Republican, believes his state “would lead the parade to opt out of all the federal mandates” that were built into the Affordable Care Act.

But U.S. Rep. Carlos Curbelo, also a Republican, is not so sure his state, Florida, would follow suit. “I would highly doubt that any governor, especially the governor of a large state like Florida, would seek a waiver. I just don’t think that any state would want to carry the burden of managing health care more than they already do, through Medicaid,” Curbelo told The Times.

What’s Still in the Bill?

Much of the original text of the bill remains the same.

The AHCA still includes a measure that phases out Medicaid expansion and would cut funding to the program by $880 billion over the next decade.

And similarly on the Medicaid front, an earlier amendment that shifts the cost of New York’s Medicaid program away from its counties and onto the state still remains.

The so-called Collins Amendment, as Route Fifty has reported before, puts New York county officials in a tough position. On the one hand, the counties have been advocating for relief from their Medicaid expenses for the better part of fifty years, but on the other hand, according to the New York State Association of Counties, the AHCA taken as a whole would be a bitter pill to swallow.

The AHCA also still includes a provision that would eliminate the Prevention and Public Health Fund, the largest individual federal funding source set aside for disease prevention.

The fund makes up 12 percent of the U.S. Center for Disease Control and Prevention’s entire budget. And without the fund in place, state and local health departments stand to lose as much as $3 billion over the next five years.

What Happens now?

The bill is out of the House, but it still faces a tough road in the Senate, where the GOP holds a slim 52-seat majority.

At least one Republican senator, John Thune of South Dakota, has already proposed changes to the AHCA’s tax credit system. Additionally, there could be a push to change the way the Medicaid expansion is phased out. U.S. Sen. Rob Portman, an Ohio Republican, has been leading the charge on this initiative.   

Editor's Note: This article has been updated

Quinn Libson is a Staff Correspondent for Government Executive’s Route Fifty based in Washington, D.C.

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