Revised AHCA Bill Wins House Support, Moves on to Senate

House Republicans have passed a revised version of the American Health Care Act (AHCA) by a vote of 217 to 213, without any Democratic support, and despite strenuous opposition from the health care community.

The passage followed months of debate and a failed first attempt at House approval on March 24. The bill, which is expected to deprive millions of Americans of insurance coverage, now goes to the Senate where it is expected to face a more difficult test, as the Republicans there hold a slimmer majority.

Crafted as a replacement for the Affordable Care Act (ACA), the AHCA bill includes a last-minute provision for 8 billion dollars in additional funding to ensure coverage of pre-existing health conditions. This was seen as essential to garner support from Republican House members who felt the bill would not provide enough coverage for Americans. In the House, 20 Republicans and 213 Democrats voted against the revised health bill.

Republicans had contended that the ACA was expensive and structurally untenable in the short and long term, and was suffering from flagging support from the payer community. In debate leading up to the vote, Paul Ryan, speaker of the House, said the ACA “means even higher premiums, even fewer choices, even more insurance companies pulling out, even more uncertainty and even more chaos.”

The Congressional Budget Office (CBO) has estimated that 24 million people would be uninsured by 2026 if the AHCA is approved by Congress and signed into law by President Donald Trump. The bill would undo many of the signature provisions of the ACA, such as the tax on Americans who don’t purchase health insurance and the so-called Cadillac tax on high-end health plans. Also, states would not have to require payers to cover “essential health benefits,” nor would payers have to charge the same price to everyone regardless of their health history.

The House approval was immediately panned by consumer advocacy groups. “Allowing patients to be charged more for coverage based on their health status risks making pre-existing condition protections virtually meaningless,” the Cancer Action Network of the American Cancer Society wrote. “A return to medical underwriting, combined with seriously weakened standards for what constitutes good coverage through the erosion of essential health benefits, sets up a situation whereby payers can cherry-pick their customers and leave patients with serious conditions like cancer with few if any affordable insurance options,” it said.

The AHCA would also phase out the Medicare expansion that provided coverage for adults making up to 133 percent of the federal poverty line. In addition, the bill would provide for up to 883 billion dollars in tax reductions, a reversal of the shift of wealth from rich to poor that has been a hallmark of the ACA.

ASCO had previously issued a vigorous condemnation of the AHCA bill and urged the House to vote it down. It wrote that the AHCA would reduce meaningful access to high-quality care by adding provisions that would increase costs, decrease access to appropriate treatment and widen existing disparities in cancer care.

Following the House vote this week, ASCO President Daniel F. Hayes, M.D., issued the following statement: “We remain concerned that the AHCA may not include adequate pre-existing condition safeguards, and therefore does not meet ASCO’s guiding principles for healthcare reform, which call for preserving the current ban on pre-existing condition limitations. This key patient protection clearly remains jeopardized, even under the last-minute negotiated agreement to provide 8 billion dollars over five years for high-risk pools. Doubtful that this funding level comes close to covering all individuals with pre-existing conditions, many experts agree that high-risk pools still deprive the most-ill patients of critical medical care. Even the sponsors of the compromise measure have expressed uncertainty about the adequacy of this funding level. We now call on the Senate to work with us toward real healthcare reform that will improve cancer care for all Americans.”

In recent public statements, the Association of Community Cancer Centers has also expressed reservations about the bill. The ACCC said it had concerns that the insurance gains under the ACA would be reversed and that vulnerable populations, such as older and lower-income Americans, would be especially hard-hit. Changes to Medicaid programs under the AHCA, if passed, would inevitably squeeze cancer patients across the country, the ACCC said.

An earlier incarnation of the AHCA produced widespread criticism from medical and senior associations, an acidic debate on the House floor, internal conflict within the GOP, and no vote. Lacking the necessary support, the bill was pulled from consideration entirely upon the realization that it would not have the support to pass the House.

Internal deal-making sewed up GOP support for the newest version. The most striking difference between this version of the bill and the previous one is the Meadows-MacArthur amendment, allowing states to eliminate the ACA’s pre-existing condition requirements (or protections, depending on which party had the floor).

The early iteration of AHCA was partially sunk by the most conservative elements of the GOP, led by the stalwart House Freedom Caucus, which believed the bill was not a sufficient departure from the ACA. Even in March, the draft was amended on several points to appease the Freedom Caucus, but still failed to garner the support it needed. The Meadows-MacArthur amendment helped win over the Freedom Caucus.

Concessions were made to the party’s center as well. Yesterday, often-moderate Rep. Frank Upton (R-Michigan) flipped to favor the bill after the 8 billion dollars was written into it to assist those with pre-existing conditions. Upton had been previously critical of the impact the AHCA may have on those individuals, though critics on the other side of the aisle argued that the 8-billion-dollar concession is still inadequate.

While Republicans worked hard to unite their own ranks to vote for the legislation, there was no necessity to appease Democrats.

Members of the minority party continued their scathing criticism of the bill, reiterating everything they had objected to in March while claiming the state waiver on pre-existing conditions had “made a bad bill even worse.”

Many Republicans cited the tenuous insurance situation in Iowa as incentive to vote for the bill. Iowa began the year with three providers broadly covering citizens of the state through ACA exchanges. Two have since pulled out, and the last has threatened to as well, which would leave all but five of the state’s 99 counties without a single insurance option.

A hot point of contention was an effort to get the revised AHCA on the floor before the CBO was able to update its pre-revision appraisals, which featured striking numbers. The CBO at the time predicted tens of millions of Americans would wind up uninsured in the following decade, as many as 24 million.

The bill can be seen as the first major legislative victory for Donald Trump and the new Republican majority. It is still expected to face a fierce battle in the Senate before it can reach Trump’s desk and become law.