NYAPRS Note: Despite several rounds of discussion, White House and House GOP members have not reached agreement on the nature of a second attempt to replace the Affordable Care Act (Obamacare).
As a result, opponents of these efforts must get out in full force in the coming weeks (see next posting).
As background, here's a quick breakdown from AOL.com of the two important elements that reports suggest the new deal on the AHCA could allow states to repeal:
- Essential health benefits: These are a baseline of types of care, from prenatal treatment to emergency room visits, that insurers have to cover in their plans. By removing these provisions, insurers could offer plans at a cheaper price, but those plans could cover far fewer types of healthcare needs. Conservatives assert this would increase "choice" for consumers, while opponents say it would leave many people with insufficient coverage.
- Community rating: In the most basic sense, community rating means insurers can't charge people different premiums except for adjustments based on age and cost-of-living adjustments in different locations.
Pence's Obamacare Diplomacy Fails To Yield A Deal
By Rachael Bade and Josh Dawsey Politico April 5, 2017
The White House’s latest last-ditch effort to save the House GOP’s Obamacare replacement bill hit a wall Tuesday night, as conservative and moderate Republicans met and realized they had different understandings of the changes sought by top Trump administration officials.
Conservatives in the House Freedom Caucus say Vice President Mike Pence, chief of staff Reince Priebus and budget director Mick Mulvaney sought to win their votes by offering a repeal of major Obamacare regulations during a Monday night meeting. But moderates who met with the same Trump officials hours before were told the changes wouldn’t be as far-reaching.
…The crux of the issue stems from different interpretations about what White House officials — and House Republicans, for that matter — mean when they say they want to retain Obamacare’s protections for sick individuals or those with pre-existing conditions.
Everyone, from President Donald Trump to conservatives to moderate members of the GOP conference, say they want to keep these protections. But they disagree over which Obamacare regulations comprise the fundamentals of that safeguard.
Case in point: Pence told hard-line Freedom Caucus members Monday night that changes to the bill would allow governors to opt out of Obamacare’s “community rating” provision, which prohibits insurers from charging higher premiums to people who are sick, are older or based on their gender. Without it, insurers could charge more to people with cancer or other medical conditions, though supporters say it would drive down premiums for healthy people.
Meadows said they were told governors would be allowed to opt out for “all community ratings with the exception of gender.”
But moderate GOP members who met with Pence the same day say they were under the impression that governors would only receive “community rating” flexibility based on a person’s age — not their illness or other factors. They argue the “community rating” provision goes hand-in-hand with Obamacare regulations that bar insurance companies from rejecting people with pre-existing conditions — and that without it, the pre-existing conditions protections are meaningless because insurance companies could price sick people out of the market by charging them exorbitant premiums.
That’s not the only discrepancy. Some Freedom Caucus members say the White House also floated the idea of letting governors opt out of the law’s “guarantee issue,” which bars insurance companies from turning away sick people. The idea, Meadows said, would be to send such individuals to state-run risk pools where they can get insurance partially subsidized from a $115 billion “stability fund” that would go to the states to help keep premiums down.
“This high risk pool… is a 100 percent guarantee,” Meadows said late Tuesday. "Guarantee issue happens automatically with this back stop. You guarantee coverage 100 percent of the time. With that, the guarantee issue from an individual carriers point of view becomes a moot point.”
But that’s not at all what centrists said they heard from Pence. Multiple sources said that Energy and Commerce Chairman Greg Walden, who met with Pence, other White House officials and centrist members of the conference Monday, had started drafting legislative text that would only allow the opt-out for age, not everything else. And it would keep the guarantee issue in place, which other Republicans in the conference view as essential in their replacement plan….
White House's Proposed AHCA Tweaks Under Discussion; House Vote Not Expected Immediately
Inside Health Policy April 04, 2017
A vote on the newly tweaked version of the American Health Care Act isn’t likely this week before Congress breaks for recess, Republican lawmakers saidTuesday(April 4). House Speaker Paul Ryan (R-WI) said health reform talks will continue, following a meeting where Vice President Mike Pence, Office of Management and Budget Director Mick Mulvaney, White House Chief of Staff Reince Priebus and members of the House Freedom Caucus discussed changes that potentially could shore up support for the bill.
Lawmakers said two changes under discussion are: letting states apply for waivers from essential health benefit requirements for private insurance plans and adding money to the state stability funds.Yet members of the House Freedom Caucus who staunchly opposed the AHCA in its original form said they haven’t seen enough to be convinced.
“At this point all we have is some ideas coming from the White House, not from the House Freedom Caucus, and we’d like to see any proposal before we really comment further on it,” Rep. Justin Amash (R-MI) saidTuesday.
A White House spokesman said that as of press time there is no update about which specific provisions the president would endorse as part of a revised bill, or when he wants to see a vote.
Rep. Ryan Costello (R-PA) said that while everyone in the Republican conference wants to come together to move on health reform, he doesn’t see leadership forcing another vote so quickly.
“I think [Ryan’s] point was that we’re not going to put a timeline on this,” Costello said.
Ryan didn’t bring forward any specific changes he would like to make to the bill, Rep. Kevin Cramer (R-ND) said, and discussions on many ideas -- including giving states the ability to opt out of essential health benefits through a waiver -- are “taking place among the diverse groups within the conference,” Cramer said.
"These discussions, while not taking place broadly also can't take place in a vacuum so authorizing committees and leadership, as well as the other diverse groups, continue to talk," Cramer said.
Rep. Chris Collins (R-NY) said leadership and the committees of jurisdiction -- the Energy & Commerce and Ways & Means committees -- need to guide the actual negotiations over the details of the bill rather than have those details debated in ad-hoc meetings of various caucuses.
Collins, a member of the moderateTuesdayGroup, also said that he believes the proposals being floated by the White House should bolster support for the bill, but that Ryan did not offer policy specifics. The state stability funds are ostensibly meant for states to shore up their high-risk pools. Although the original bill didn’t mandate how states had to spend most of the money, additional funding for mental health, substance abuse disorders and maternity care was added to the stability fund through an amendment at the Rules Committee late last month. Rep. Mark Walker (R-NC), who chairs the conservative Republican Study Committee, said there hadn’t been discussion on whether strings would be legislatively attached to the new funds.
Collins said that if anything beyond the essential health benefits package for insurers is proposed as optional for states, it might hurt the bill’s chances with moderates who are concerned about lifetime limits, children under age 26 staying on their parent’s plans, and the pre-existing condition provision.
Collins also said he wasn’t certain on whether a modified bill would make the ACA's community rating provision optional for states, but that if it did it might hurt the vote count. He said that while he wouldn’t support such a measure himself, it wouldn’t change his vote because New York protects the age-band limits in state law.
House Freedom Caucus member Rep. Dave Brat (R-VA), who staunchly opposed AHCA up until Ryan pulled the vote, said he was optimistic “good things are happening” but he wants to make sure anything that the House passes will bring down premiums. Brat also said he wants to see how strict the waiver process for opting out of essential health benefits would be for states, adding that states should be able to take action to lower premiums.
Amash said details need to be hammered out and it would be a mistake to rush another vote on the House floor.