2017 Action of the Affordable Care Act
Affordable Care Act Update
Congress spent much of 2017 focused on the repeal and replace of the Affordable Care Act (ACA). After many unsuccessful attempts to pass legislation in both the House and the Senate, the Trump Administration used executive authority to make significant changes to the law. In response, Senators Alexander and Murray introduced the Bipartisan Health Care Stabilization Act of 2017, with the intention of helping to stabilize the insurance marketplace. Below is a summary of Congress and the Administration’s actions on repeal and replace of the ACA that occurred in 2017
January
The fiscal year (FY) 2017 budget resolution was introduced and approved, paving the way for consideration of legislation focused on repealing the ACA. The resolution included specific reconciliation instructions requiring the four committees of jurisdiction – Ways and Means and Energy and Commerce in the House, and Finance and Health, Education, Labor and Pensions (HELP) in the Senate – to draft reconciliation legislation achieving at least $1 billion in deficit reduction over ten years. Reconciliation legislation is limited to amending provisions in law that would have a federal budget consequence and only requires a majority of votes in the Senate (50 votes) rather than the usual 60.
February
ASH wrote to the four committees of jurisdiction – Ways and Means and Energy and Commerce in the House, and Finance and Health, Education, Labor and Pensions (HELP) in the Senate - outlining the Society’s priorities related to access to care for patients with hematologic diseases and disorders.
March
The U.S. House of Representatives released legislation, the American Health Care Act (AHCA), to repeal and replace the ACA. This legislation repealed the ACA's Medicaid expansion after 2020 and would convert Medicaid to a per capita allotment or a block grant system. An amendment to the legislation, introduced by Representatives Tom MacArthur (R-NJ) and Mark Meadows (R-NC), allowed for states to apply for waivers to opt out of certain ACA requirements, including the essential health benefits, community rating, and age rating. ASH opposed this piece of legislation because of concerns that it would reduce overall access to coverage and treatment and would greatly impact patients with hematologic diseases and disorders.
ASH co-signed a letter with several other medical specialty societies urging Congress to address out-of-pocket costs in any new ACA legislation and a letter expressing concerns about the changes to Medicaid under the AHCA.
May
On May 4th, the U.S. House of Representatives voted on and passed the HR 1628, the American Health Care Act, on a party line vote of 217-213. The bill moved to the Senate for further consideration.
June
In late June, the Senate released its own version of legislation to repeal and replace the ACA, the Better Care Reconciliation Act (BCRA). While this legislation maintained the ACA requirement that insurers accept everyone and charge the same rates, it did allow states to waive other requirements, such as the rules for what benefits insurers must cover. Beginning in 2020, Medicaid would be moved to a block grant or per capita program, increasing the financial burden on states and most likely forcing many states to cut back on coverage. Additionally, the legislation would allow insurers to charge older consumers five times more than younger consumers, an increase from three-to-one under the ACA. ASH opposed BCRA for the same reasons the Society opposed the AHCA, because of concerns that this piece of legislation would reduce overall access to coverage and treatment and would negatively impact patients with hematologic diseases and disorders.
ASH, along with several other public health organizations, signed a letter opposing the repeal of the Prevention and Public Health Fund because of the impact this would have on discretionary health spending including funding for the Centers for Disease Control and Prevention and other federal public health agencies. Additionally, ASH wrote to all US Senators again outlining the Society’s priorities as Congress moved forward with attempting to repeal and replace the ACA. Later in the month, ASH again signed letters to defend Medicaid funding and to oppose the repeal of the Prevention and Public Health Fund.
July
In late July, the U.S. Senate had its chance to vote on and pass repeal legislation; however, the legislating body could not garner enough support to pass any of the bills presented. These included a piece of legislation from 2015, that would repeal but not replace the ACA; the Better Care Reconciliation Act, a bill the Senate had been working on for two months; and finally, what was being called the “skinny repeal,” bill which would have rolled back several key provisions of the ACA. Three Republican Senators, Susan Collins, Lisa Murkowski, and John McCain, joined Democrats to vote against this final measure.
September
Senators Cassidy, Graham, Heller, and Johnson introduced a new amendment to H.R. 1628, the American Health Care Act. The legislation would have provided block grants to states to cover the ACA’s premium subsidies, cost-sharing reduction payments, and Medicaid expansion funding. The bill would also have allowed the states to remove the essential health benefits (EHB) requirement, which would have undermined the ACA’s patient protections, and would have moved Medicaid to a per-capita allotment, making it more difficult for states to respond to fluctuations in the price and demand for health care services. In order to pass legislation under the budget reconciliation rules which only require a majority of votes in the Senate (50 votes), the legislation would have to be approved before October 1st; however, due to a lack of support in the Senate, the amendment was never voted on.
ASH wrote to all US Senators opposing the Graham-Cassidy Amendment.
October
After Congress repeatedly failed to pass legislation to repeal and replace the ACA, President Trump used the power of the executive branch to make two significant changes to the law, both of which could have a substantial impact on access to care.
The first executive order seeks to increase competition by facilitating access to association health plans (small businesses can join together to purchase insurance coverage through associations), short-term limited duration insurance products (plans that last less than a year), and health reimbursement arrangements (employers can give employees money to purchase insurance rather than provide it directly). Nothing is changing immediately; rather, President Trump has directed several government agencies to draft regulations to implement these new policies over the next 60 to 120 days. Experts disagree about whether and how these policies can be implemented via regulation, so it is not clear what the effects will be. Since association health plans and short-term insurance products do not need to follow a number of ACA patient protections including the requirement for the essential health benefits, they could appeal to younger, healthier people who seek less expensive, and therefore less comprehensive coverage. This would raise costs for people who need more complete coverage.
Secondly, after months of threatening to do so, the Trump Administration announced its decision to end the cost-sharing reduction (CSR) payments to insurers. The CSR payments were set up as subsidies to insurance companies to help pay out-of-pocket costs for low-income individuals, available to people with incomes of 100 percent to 250 percent of the federal poverty level. Currently, about seven million people benefit from the CSR payments but the change could destabilize the marketplace and force insurers to drastically increase premiums, impacting millions of others not currently benefiting from these payments. In August, the Congressional Budget Office estimated that if the CSR payments were stopped, premiums would increase by 20 percent in the following year.
Senators Lamar Alexander and Patty Murray, the ranking Republican and Democrat on the Senate Health, Education, Labor and Pensions (HELP) Committee, respectively, introduced the Bipartisan Health Care Stabilization Act, to help stabilize the insurance marketplace. The legislation was introduced with the support of 12 Republicans and 12 Democrats, and would restore the cost-sharing reduction (CSR) payments, recently cut off by the Administration. The legislation would also expand access to catastrophic plans, restore the funding for outreach and enrollment activities, and provide greater flexibility to states when determining the affordability of health insurance. ASH sent a letter to all US Senators in early November expressing the Society’s support for this legislation.
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