House Passes American Health Care Act, Starting the Path for Repeal of Affordable Care Act of 2009


This afternoon, the House voted to enact the American Health Care Act (AHCA). This is the initial legislative step in a process intended to eliminate major portions of the Affordable Care Act. Most folks recognize that this was the second attempt on this bill, after it came up short a few weeks before. There were significant revisions between today’s legislative language and the prior one. The MacArthur amendment establishes a permissible state waiver, allowing states to: increase the age rating ratio above the 5:1 ratio; specify the essential health benefits that are required to be covered; and implements a health status rating for states operating a risk mitigation program or participating in a Federal Invisible Risk Sharing Program. The Upton amendment provides an additional $8 billion over five years to offset or reduce premiums or other out-of-pocket costs for certain individuals with pre-existing conditions.

One unprecedented characteristic of today’s vote was that it was enacted without a CBO score being rendered on this revised bill, as virtually no Medicare, healthcare or other major policy legislation is enacted without an assessment of costs by CBO, and if there is a cost identified by CBO, Congress also identifies one or more steps to create offsetting savings equivalent to any increased costs attributed to the bill by CBO. For instance, the Affordable Care Act followed the details of a CBO score that identified costs and offsetting savings amounting to $750 billion over ten years, and many issues O&P has faced, e.g., RAC audits, find their genesis in those CBO-scored offsetting “savings.” While the American Health Care Act was enacted without any announcement from CBO, it is likely that this version shares the likely outcome identified by CBO on the prior version that AHCA’s enactment would result in a reduction by 24 million the number of Americans who have health care insurance coverage.

The House vote is a first step-it will not alone kill the ACA. As noted, the House bill is an initial step, and with the House having acted to repeal the ACA so many times previously, the body most opposed to the ACA has started the process of repeal. Now, the real action will be in the Senate. The plan is to move the American Health Care Act in the Senate via the budget reconciliation process-that means filibuster is avoided, but also this process is limited to items that have a demonstrated federal budget financial aspect. Assuming that most, if not all Democrats in the Senate will be inclined to oppose this bill, it is important to note that there are several Republicans, e.g., Sens. Collins, Murkowski, and one of our AOPA Policy Forum speakers, Sen. Cassidy, who have some significant reservations about the bill passed by the House. In the Senate, we do not expect action in the short term, nor do we expect them to consider the bill as passed in the House. We believe the Senate is likely to move to revise the bill, but they will move at Senate pace.

Most polling has shown very significant public opposition to the American Health Care Act’s provisions. Also, most major health organizations, groups like the American Medical Association, the American Hospital Association, and the American Association of Retired Persons oppose the AHCA.

So, in conclusion, the battle over the ACA has been re-engaged via the vote today in the House, and the House continues to take a fairly dramatic role on the Affordable Care Act. Ironically, in 2009, Democrats cobbled together 220 votes with just one GOP vote (most folks forget Rep. Joseph Cao, R-LA). Today, GOP cobbled together 217 GOP votes to rebut much of it. Many argue that there ought to be a better way for our patients.

Obviously, we will continue to watch closely actions relating to major repeal or revisions to the Affordable Care Act. Certainly discussions in recent weeks relating to reducing: (a) the number of insured Americans; (b) certainty of national standards for essential health benefits; and (c) pre-existing conditions will be important to our patients, and to those serving them at all levels in O&P.