ASHINGTON — It’s the first step toward fulfilling a promise Republican legislators have campaigned on for seven years. But even though the House voted Thursday to repeal major elements of the Affordable Care Act, the effort still faces a number of major political hurdles, not the least of which is that little is known about this legislation’s impacts.
That’s because the GOP leadership muscled Thursday’s vote through before the Congressional Budget Office, the legislative branch’s nonpartisan analytics arm, had a chance to fully assess the latest bill as it had with a previous version.
The legislation now heads to the Senate, where Republicans hold just a two-seat advantage. GOP senators ranging from moderates to hard-line conservatives have expressed concerns about early versions of the bill — some about potential Medicaid rollbacks, others about the prospect of pulling federal funding for Planned Parenthood, others still who said previous versions left too much of the Affordable Care Act intact.
The Senate is likely to make substantial changes to the House bill, meaning the House may have to vote on a bill much more moderate than the one it approved Thursday. Swaying the far-right Freedom Caucus was hard enough the first time, and the swing votes could prove elusive for the House encore.
The Senate will also have to wait on a CBO score so that its parliamentarian can determine whether the chamber is even allowed to vote on the bill, which under the rules of its budget reconciliation process cannot raise the budget deficit.
Here’s what we know, as of Thursday, about the winners and losers from the House vote:
Insurers in states that apply for waivers to the new rules will be allowed to charge substantially higher premiums to patients with preexisting conditions, either recouping some of their losses on expensive patients or discouraging high-cost patients from even purchasing insurance.
The repeal of the individual mandate — requiring everyone to purchase insurance — is also advantageous to insurers, counterintuitively. Instead of paying a tax penalty to the federal government for non-coverage, consumers would effectively pay a premium penalty to the insurer when they next purchase insurance. The bill’s “continuous coverage” provision allows insurers to hike premiums by 30 percent for people who had a gap in insurance coverage of 63 days or greater.
Young, healthy people
Again, there’s no CBO projection. But estimates for the previous version of the American Health Care Act predicted the legislation would end up “substantially reducing premiums for young adults.” The same is likely true for this bill, which eliminates the individual mandate and could allow insurers in some states to tailor skimpier plans to thriftier consumers. Young people who don’t buy insurance wouldn’t face an immediate penalty, and those who do purchase it could likely buy cheaper “catastrophic” plans that weren’t allowed under Obamacare. Oh, and one of the ACA’s most popular provisions — allowing young people to stay on their parents’ plans until age 26 — will remain in place.
High earners will benefit from the elimination of a tax used by the Affordable Care Act to fund Medicaid, which hurts Medicaid’s long-run solvency. Those in upper income brackets would no longer have to pay an 0.9 percent tax on annual income exceeding $200,000.
Americans with preexisting conditions and older Americans
The AHCA, like the Affordable Care Act, continues to mandate that insurance companies offer plans to patients with preexisting conditions. But the bill, and especially a recent amendment from Representative Tom MacArthur, a moderate Republican from New Jersey, could make the regulation a moot point in some states.
The ACA “age band,” which prevented insurers from charging older people more than three times what they charge younger, healthier people, is being extended from 3:1 to 5:1 under the new bill. If states apply for a waiver to some of the Obamacare regulations, that age band could be extended further, and insurance companies could be allowed to charge people with preexisting conditions much higher premiums than allowed under the ACA. While technically they would have to offer insurance to all, the costs for some plans could make them cost-prohibitive.
Some states will provide for “high-risk pools” to cover high-cost patients instead of having the full private insurance market subsidize their plans — but experts say they will be underfunded.
Hospital groups opposed this legislation. So did patient groups, ranging from the American Diabetes Association to the March of Dimes to the National Organization of Rare Disorders. The AARP opposed it, too, and a national school superintendents association even got involved, opposing Medicaid cuts that would upend special education programs at schools around the country.
But even that bulwark of opposition didn’t sway Republicans — which bodes poorly for the level of influence those groups will wield until at least the 2018 midterms.
The words “Planned Parenthood” don’t appear in the AHCA. But the bill creates a classification for “essential community providers” that are “primarily engaged in family planning services, reproductive health, and related medical care” and that provide for abortions other than those performed in the wake of rape or incest, and whose reimbursements from federal and state governments totaled $350 million or greater. In other words, Planned Parenthood. Providers within that category are barred from receiving Medicaid dollars. The bill therefore creates a huge hole in the organization’s revenue structure, and it’s unclear how financially viable some clinics will be if the provision passes the Senate. Then again, at least two GOP moderates in the Senate have expressed reservations about any sort of Planned Parenthood funding repeal.
Democratic campaign arms are already running health-care-oriented ads in advance of the 2018 midterms. Many moderate Republicans in the House expressed major reservations about the bill they voted for Thursday, and most of the moderates come from swing districts that will be Democratic targets in 2018. And in a year when the Democrats will be defending 25 Senate seats, the numerous red-state Dems in the Senate just gained a campaign issue. Health care, no matter what the Senate does with this bill, is looking like the biggest non-Trump campaign issue for the next midterm cycle. And MacArthur, who introduced the late-stage amendment after negotiating with the Freedom Caucus, could be on his way out as the leader of the moderate Tuesday Group.