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Tuesday Aug 15, 2017

The ACA survived. Now what?

"I've got a hundred million reasons to walk away. But baby, I just need one good one to stay."
-- Lady Gaga

For the past seven months, Washington, D.C., has been consumed by a legislative fight that was seven years and two presidential elections in the making -- the repeal of the Patient Protection and Affordable Care Act. In the early morning hours of July 28, the legislative effort to repeal and replace the ACA came to a dramatic conclusion in one of the most stunning moments in modern Senate history.

A woman holds a sign in support of the Patient Protection and Affordable Care Act during a rally in Washington, D.C. [Image used in accordance with Creative Commons Attribution-ShareAlike 2.0 license]

As a refresher, the issue of repealing the ACA has been a staple of our political environment since March 2010 -- immediately after its enactment. The legislative efforts were, for the most part, largely symbolic between 2010 and 2016. However, the end of the Obama administration created a sense of optimism among repeal advocates, and the issue was prominent during the 2016 presidential and congressional campaigns. Without question, the issue of whether or not the ACA should be repealed was a top domestic agenda item in the 2016 elections. Many voters cast their ballots for candidates based on their position on the ACA.

After the election, the dynamic and expectations changed. Republicans had complete control of the federal government. The symbolic votes made by the 113th and 114th Congresses were over. Repeal of the ACA was a day one agenda item for the GOP, and efforts to repeal the ACA began in early January when the House and Senate approved a budget resolution that included reconciliation instructions on repealing and potentially replacing the ACA.

Despite the fast start, things got complicated when, in late January, numerous Republicans publicly opposed efforts to repeal the ACA without a replacement policy available. During the next six months there was a series of starts and stops with an ample supply of plot twists, double-crosses, and betrayals to keep things interesting. House Republicans, after being forced to pull their initial bill due to lack of support, passed the American Health Care Act (AHCA; H.R. 1628) on May 4 by a vote of 217-213(www.washingtonpost.com). Twenty Republicans voted against the proposal.

The game was on, but problems were becoming more pronounced by the day. The realization of what repeal meant -- millions losing coverage, premium and deductible increases and the devastating impact the legislation would have on older adults -- was settling in, and the politics of these outcomes led many Senators to pump the brakes.

After nearly two months of negotiations, Senate Majority Leader Mitch McConnell, R-Ky., introduced the Better Care Reconciliation Act (BCRA). Negotiations were over. McConnell was ready to move forward and announced, "It's time to vote." Consideration of the BCRA would take place the week of July 24. The outcome was unknown. It would be a show-down.

The week started on a dramatic note when Vice President Mike Pence broke a 50-50 tie on the motion to proceed, which allowed the full Senate to debate and amend the House-approved AHCA.

During the next three days, the Senate debated and considered a number of proposals, but there were four key votes. Those votes were on the BCRA, full repeal of the ACA, a Medicare-for-all proposal, and the so-called BCRA skinny bill. The Senate considered and rejected, on bipartisan votes, each of these proposals as follows:

  • BCRA failed 43-57
  • Obamacare Repeal Reconciliation Act (ORRA) failed 45-55
  • Medicare for All failed 0-57 (with 43 voting "present"); and
  • Better Care Reconciliation Act Skinny Repeal failed 48-52

When the dust settled around 3 a.m. on July 28, ACA repeal had failed in every form, and McConnell announced that the Senate would begin work on other priorities. The ACA had survived for the time being -- damaged, but standing.

I chose the lyrics from Lady Gaga's song Million Reasons because it captures, in my opinion, the debate around the ACA. The ACA remains an imperfect law. To many, there are a million reasons why it should be repealed. However, at its most fundamental level, the ACA changed the country by establishing health care coverage as a right for all citizens. (I look forward to your comments on this sentence!) The inherent value of guaranteeing health care coverage for each citizen is the single reason why the law should stay. We, as a country, have settled the question of whether guaranteed coverage should be extended to each citizen, regardless of their demographic, economic and health status. The questions remaining are around how we provide said coverage.

So, where do we go from here? On July 17, the AAFP sent a letter to Sens. McConnell and Charles Schumer, D-N.Y., outlining a set of bipartisan policy recommendations. Our letter opened with a recommendation that there be a pivot from repeal to improve.

"It is time to move beyond our current health care debate that is focused on repealing major portions of current law and seek bipartisan policies that build on our collective successes, address ongoing challenges, and improve our health care system for current and future citizens," the AAFP said.

The proposed set of policies outlined in our letter are well-positioned to increase access to affordable and meaningful health care coverage for all Americans. They place an emphasis on establishing primary care as the foundation of our health care system at the individual and population levels. They promote increased payment for family physicians, especially in the public insurance programs. We also have been mindful to promote policies that begin to remove the financial barriers many insured individuals experience due to high deductibles and co-pays. Finally, we introduced a new proposal that would allow individuals between the ages of 55 and 64 who purchase their insurance on the individual market to purchase that coverage through a Medicare Advantage plan.

The health insurance marketplace is fragile and needs to be shored up, and soon. The costs of health care continue to increase at alarming rates, and individuals and families are growing more disconnected from their insurance due to rising deductibles and out-of-pocket expenses. There is much work to do and the AAFP started working on potential solutions immediately following the Senate vote.

Thank you to those who collaborated with us during the past seven months. I know many of you believe that the ACA should be repealed and replaced. I understand your position(s), but I can assure you the legislation approved by the House and considered by the Senate was not the answer. These proposals took the flaws of the ACA and exacerbated them. They would have hurt tens of millions of people, including those with employer-sponsored insurance. In short, they were bad proposals, and we are better as a country that they failed. Now, let's get to work on improving our health care system. #stayloud.

Posted at 07:00AM Aug 15, 2017 by Shawn Martin

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ABOUT THE AUTHOR



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.