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Tuesday Sep 26, 2017

Here We Go Again: GOP Attempting ACA Repeal

Summer has come and passed. The innocent can never last. Wake me up when September ends.
-- Green Day

This week is shaping up to be one for the history books. How history records the events of the week will be determined by a half dozen U.S. senators. Regardless of what happens, the choices made will impact the American people for years to come. Yes, health care reform is back in a very big way.

[Interior view of Capitol rotunda looking up]

After devoting the first seven months of 2017 to attempts at repealing and replacing the Patient Protection and Affordable Care Act (ACA) before seeing their efforts fail late one July night, Republican legislators are prepared to make one last push to repeal the ACA. This week, the Senate will consider an amendment to the American Health Care Act (AHCA; H.R. 1628) offered by Sens. Lindsey Graham, R-S.C.; Bill Cassidy, R-La.; Dean Heller, R-Nev.; and Ron Johnson, R-Wis. The proposal, better known as Graham-Cassidy or "GCHJ," seeks to repeal major portions of the ACA.

How we got here is the subject of great speculation, but the mechanics are more easily understood. In July, the Senate considered the AHCA. As part of this process the Senate considered several amendments, all of which failed. After a week of debate, the Senate process came down to a make-or-break vote on the so-called "skinny repeal" proposal from Senate Majority Leader Mitch McConnell, R-Ky. That vote failed in dramatic fashion when Sen. John McCain, R-Ariz., voted no.

Here is where our journey takes a detour. Although all major amendments offered were defeated, the Senate never voted on the pending legislative item, which was and remains the AHCA -- H.R. 1628. At the conclusion of the failed vote on the skinny-repeal amendment, McConnell procedurally moved the Senate off the AHCA as the pending legislative item and proceeded to other Senate business.

However, later in the day, he placed the AHCA back on the Senate calendar as a "pending business item," thus enabling him to bring it back to the Senate floor at some point in the future. That future is this week.

Since the AHCA is a pending item, it is subject to amendment, and the GCHJ proposal is that amendment. So, here we are. The GCHJ is similar to a proposal developed by Sens. Graham and Cassidy earlier this summer. That proposal was not considered as part of the Senate's proceedings in July. These are six major provisions of the proposal:

  • Establishes a per-capita cap funding system for the Medicaid program starting in 2021.
  • Ends the Medicaid expansion and its current federal financing on Dec. 31, 2019.
  • Ends the tax subsidies available to low- and moderate-income families for the purchase of health insurance on the Health Insurance Marketplace on Dec. 31, 2019.
  • Creates a waiver process that would allow states, at their discretion, to opt out of current consumer protection and insurance reform protections. Notably, this means states would not be required to cover the 10 essential health benefits, and insurers could charge individuals with pre-existing conditions more for their coverage.
  • Creates a block grant program to distribute financial resources to the states, in accordance with a complex and largely undefined formula, for the purposes of providing health care coverage to eligible populations as determined by the state.
  • Ends the individual and employer mandates retroactive to the 2016 tax year.

Analysis conducted by Avalere(avalere.com), a nonpartisan Washington, D.C., research firm, concluded that the Graham-Cassidy proposal would result in reductions of federal support to the states for their health care programs (Medicaid and Health Insurance Marketplaces) of $215 billion by 2026 and more than $4 trillion during the next 20 years.

Avalere's analysis also evaluated the impact of the proposal on the individual states and found that for years 2020 to 2026, the bill, as compared to current law, would result in 34 states and the District of Columbia experiencing cuts to the levels of federal support for their health care programs. Seven of the 34 states would experience cuts of greater than $10 billion. Only 16 states would experience an increase in funding during this period. By 2027, the cuts become more severe, with 39 states and the District of Columbia facing reductions in funding, and 18 states facing reductions of greater than $10 billion. By 2027, only 11 states will see increases in funding.

"The largest impact of the proposed bill would be the reallocation of federal dollars between states," Avalere noted. "Medicaid expansion states and states that have enrolled a high number of people in insurance affordability programs would be most adversely impacted."

This legislation is easily the most complex and potentially damaging repeal bill considered by the 115th Congress, largely due to the cuts and changes it would make to Medicaid. However, we at the AAFP are equally concerned with provisions that would allow states to use the waiver process to weaken, if not outright avoid, the consumer protections and benefit protections currently in place.

Last week, the AAFP sent a letter(2 page PDF) to the sponsoring senators laying out our concerns with their proposal and expressing opposition to the bill. The AAFP also joined the Group of Six (AAFP, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association and the American Psychiatric Association) on a Sept. 13 letter to McConnell and Senate Minority Leader Charles Schumer, D-N.Y.(2 page PDF), that raised concerns with the proposal and urged the Senate to work in a bipartisan manner to stabilize insurance markets instead of focusing solely on repealing current law.

This Graham-Cassidy proposal is deeply troubling and inconsistent with AAFP policy on health care coverage and financing. Unfortunately, it has a chance to pass. Should it pass the Senate, we anticipate the House will act quickly to do the same. It is possible that by Oct. 1, the Graham-Cassidy proposal could be sitting on the president's desk waiting to be signed into law. We shouldn't sit quietly and allow that to happen.

The AAFP is working hard to defeat this proposal. I urge you to join us in our efforts by calling your senators and urging them to oppose the Graham-Cassidy proposal. You can also use our Speak Out tool to send a letter to your elected officials.

I will close with this. Our health care system is not perfect. In fact, in many ways, it is deeply flawed. However, taking health care coverage away from millions of people is not the path to a better system. Allowing insurers to discriminate against people with pre-existing conditions is not the path to a better system. Restoring "mini-med" plans that have extremely high deductibles and very limited benefit packages is not the path to a better system.

As we stated in our letter to the bill's sponsors, it is time "to set aside efforts to repeal the ACA and focus on improving current law in ways that expand access to affordable coverage, reconnect patients back to primary care, stabilize insurance markets and begin to lower health care costs. There are bipartisan solutions to challenges we face, and the AAFP is standing ready to partner with you and your colleagues (senators) to identify, develop and implement those solutions."

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Stephanie Quinn, 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.