ACA Repeal and Replacement Update – April 27, 2017

Top takeaways from the week: 1) House Republicans released bill text for the latest amendments to the American Health Care Act (AHCA), 2) Despite the compromise offered by the latest amendment, it is unclear whether Republicans have enough support to bring the bill to a vote this week, and 3) House Speaker Ryan announced that the fiscal year 2017 appropriations bill currently being negotiated will not include funding for the ACA’s cost-sharing reductions (CSRs); instead, the White House has pledged to continue payments.

American Health Care Act Amendments –

This week, House Republicans released bill text for an amendment to the American Health Care Act (AHCA) (H.R. 1628), in the hopes of finding a compromise between moderate Republicans wary of coverage losses and conservative Republicans who oppose the ACA’s mandates and insurance requirements.

The amendment, brokered by Tuesday Group co-chair MacArthur (R-NJ) and House Freedom Caucus Meadows (R-NC), would allow states to opt out of certain ACA requirements. Under the proposal, states can apply to:

  • Specify their own set of essential health benefits, starting after January 1, 2020;
  • Establish age rating ratios higher than that already established by the AHCA, for plan years beginning on or after January 1, 2018; and
  • Eliminate community rating for individuals who have not maintained continuous coverage by allowing issuers to incorporate health status into premium rates instead of applying a continuous coverage premium surcharge, beginning in plan year 2019. States seeking this option must either implement a high-risk pool or some other financial assistance program, or participate in the federal invisible risk sharing program.

States can submit applications to HHS to opt out of one or more of those provisions, but must justify how the proposal would either (1) reduce average premiums for coverage, (2) increase enrollment, (3) stabilize the market, (4) stabilize premiums for individuals with pre-existing conditions, or (5) increase the choice of health plans. Bill text: We have also attached several documents to this email that provide updated AHCA summaries.

An additional amendment was then introduced on Wednesday by Rep. McSally (R-AZ), removing a contested provision within the MacArthur-Meadows amendment that exempted Congressional health insurance coverage from the waivers. Press release:, Amendment text:

Timing and Support –

On Monday, the White House indicated it has no set timeline for passing the legislation, with Press Secretary Spicer noting, “I think that whenever the Speaker and the Leadership over in the House tell us that they feel confident that they have the votes, then we would encourage them to move forward.” On Wednesday, Speaker Ryan (R-WI) noted that the amendment “helps us get to consensus” but did not say whether there is enough support for it to pass.

House Ways & Means Committee Chair Brady (R-TX) noted on Wednesday that there is a “lot to like” about the MacArthur-Meadows amendment and that “it really focuses on more affordable health care, giving states flexibility…and it protects important patient protections… I think it’s important for members of the House who have not yet gotten to yes who wish to deliver on their promise to repeal and replace, to give them some time to look at, digest, think about the MacArthur-Meadows approach.” The House Freedom Caucus also announced its support for the amendment on Wednesday, noting in a statement that “While the revised version still does not fully repeal Obamacare, we are prepared to support it to keep our promise to the American people to lower healthcare costs.”

Notably, the Congressional Budget Office (CBO) informed Congress today that a score will not be available on the latest amendments if a vote is held either this week or next. The bill is widely expected to further increase coverage losses, in addition to providing greater state and insurer flexibility from the ACA’s requirements.

It is therefore unclear whether the amended AHCA can gain the necessary votes from moderates it needs to pass in the House. So far, none of the Republican moderates who opposed the original repeal bill have publicly flipped to support the new version of the bill, and several others who originally supported the AHCA are now undecided.

Several health care stakeholder groups have also weighed in against the latest version of the AHCA, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, the American Psychiatric Association, the American Medical Association, the American Hospital Association, and the Catholic Health Association of the United States. Joint Letter: AMA Letter: AHA Letter:

Cost-Sharing Reductions –

Meanwhile, this week Congress also continued to debate whether to include funding for cost-sharing reduction (CSR) payments as part of an appropriations package to fund the government through the remainder of fiscal year (FY) 2017. On Wednesday, House Speaker Ryan said that it was up to the Trump Administration to handle funding the CSRs, and that the appropriations bill will not include them. The same day, the White House assured lawmakers that it will continue paying the CSRs.

Despite the pledge from the White House, several stakeholders have continued to advocate for Congressional appropriations. AHIP noted “our position has not changed – the American people need Congress to fund CSRs now.” Additionally, the American Academy of Actuaries released an issue brief to the public that was sent to all members of Congress on Monday arguing for immediate action to stabilize the individual insurance markets, including through the continued funding of CSRs. The National Governors Association (NGA) also weighed in on Tuesday, sending a letter to House Speaker Ryan (R-WI), Minority Leader Pelosi (D-CA), Senate Majority Leader McConnell (R-KY) and Minority Leader Schumer (D-NY), urging them to fully cost the CSRs for FY 2017 through the upcoming appropriations bill and to fund CSRs for FY 2018. Last week, the National Association of Insurance Commissioners also sent a similar letter to Congress. AAA Issue Brief: