House Republican leaders plan to hold a showdown vote Thursday on their bill to repeal and replace large portions of the Affordable Care Act after adding $8 billion to the measure to help cover insurance costs for people with pre-existing conditions.
“We have enough votes,” Rep. Kevin McCarthy of California, the House majority leader, said Wednesday night. “It'll pass.”
The amendment, drafted by Rep. Fred Upton of Michigan, secured the support of Upton and Rep. Billy Long of Missouri, two key Republican lawmakers who had come out against the health care legislation earlier this week, warning that it did not do enough to protect the sick.
President Donald Trump blessed the proposal at a White House meeting with both lawmakers as he pressed hard for a vote that could at least ensure House approval of the bill. That set up the likely vote Thursday that carries enormous consequences, for his legislative agenda, for Speaker Paul D. Ryan, who has failed twice to bring the bill to the House floor – and for a U.S. health care system that has faced enormous upheaval for years, and the patients who rely on it.
The measure faces a wall of opposition from health care providers, disease advocates and retirees. Should it win House approval, vast parts of it could still be dismantled by the many Senate Republicans who are all but certain to reject the current proposal. But clearing the House is the necessary step to keep alive the Republican promise – seven years in the making – to dismantle President Barack Obama’s signature domestic achievement.
Upton predicted the bill was “likely” to pass the House, a tremendous reversal of momentum for a measure that has twice been pulled back from a vote for lack of support.
Their announcement gave a big lift to Ryan and other Republican leaders who are trying to round up enough votes to push the bill through the House this week.
“We’ve got some momentum,” Ryan told a Wisconsin radio station Wednesday morning.
Democrats and health care groups, once confident of another collapse, tried to slow that momentum. The liberal health advocacy group Families USA said another $8 billion would do little to improve the “high-risk pools” that could be set up by state governments to provide coverage to people with pre-existing medical conditions who could not find affordable insurance in the open market.
The American Medical Association and 10 organizations representing patients, including the American Heart Association and the advocacy arm of the American Cancer Society, reiterated their opposition to the House Republican bill Wednesday, as did the retirees’ lobby AARP.
“None of the legislative tweaks under consideration changes the serious harm to patients and the health care delivery system” that would result from the bill, said Dr. Andrew W. Gurman, the president of the American Medical Association. The latest changes, he said, “tinker at the edges without remedying the fundamental failing of the bill – that millions of Americans will lose their health insurance as a direct result of this proposal.”
Sen. Chuck Schumer of New York, the Democratic leader, also criticized the latest version of the legislation. “The proposed Upton amendment is like administering cough medicine to someone with stage four cancer,” he said in a statement. “This Republican amendment leaves Americans with pre-existing conditions as vulnerable as they were before under this bill.”
If House Republicans can pass the bill, it would be a moment of redemption for both Ryan and Trump, who in March suffered a resounding political defeat when they failed to muster the votes to win approval of an earlier version of the repeal bill.
The Affordable Care Act generally requires insurers to accept all applicants and prohibits them from charging higher premiums because of a person’s medical condition. Conservatives argued that this and other requirements of the 2010 health law drive up insurance costs. The House Republican bill to roll back the Affordable Care Act generally requires insurers to charge higher premiums for one year to people who allow their coverage to lapse.
At the insistence of conservative lawmakers, House Republican leaders agreed to let states apply for waivers allowing insurers to charge higher rates based on a person’s “health status.”
The original version of the Republican repeal bill would establish a $100 billion fund that states could use to help people pay for health care and insurance from 2018 to 2026. House leaders added $15 billion last month to help insurers pay claims for their sickest customers. Upton’s proposal would provide $8 billion over five years on top of that.
How far that $8 billion would go in providing coverage for people with pre-existing conditions is not clear. Upton’s proposal does not specify who would be eligible, how much of their costs would be covered or how much they would be expected to contribute in premiums.
How many states would seek waivers is difficult to predict.
But the fight over pre-existing conditions overshadowed a major reason the Congressional Budget Office estimated that the original bill would leave 24 million more Americans without health insurance after a decade: a rollback of the Affordable Care Act’s Medicaid expansion in states that adopted it. The House plans to vote for the latest version before CBO can finish a fresh assessment of its cost and impact.
Rep. Joe L. Barton, R-Texas, predicted that his state “would lead the parade to opt out of all the federal mandates” in the Affordable Care Act.
But Rep. Carlos Curbelo, R-Fla., said: “I would highly doubt that any governor, especially the governor of a large state like Florida, would seek a waiver. I just don’t think that any state would want to carry the burden of managing health care more than they already do, through Medicaid.”
Curbelo illustrated the fluid politics swirling around the repeal bill. In a Twitter post Thursday morning, he said he had just told House Republican leaders that the bill “in its current form fails to sufficiently protect Americans with pre-existing conditions.” In a late afternoon interview, he said, “I do not yet have a position on the bill.” He wanted to hear more from Upton, a respected Republican voice on health care.
The Affordable Care Act set up a special health insurance program for people with cancer, heart disease and other serious illnesses, to provide coverage until 2014, when insurers were forbidden to discriminate against people based on their health status. Claims far exceeded Obama administration estimates, exhausting most of the $5 billion provided by Congress.
The average cost per enrollee was more $32,000 a year in 2012, according to a federal report on the program, and the cost varied widely among states, from a low of $4,300 to a high of $171,900 per enrollee. Upton and Sean Spicer, the White House press secretary, said they believed that the money in the bill would be adequate.
“It’s our understanding that the $8 billion over the five years will more than cover those that might be impacted and as a consequence, keeps our pledge for those that, in fact, would be otherwise denied because of pre-existing illnesses,” Upton said at the White House.
To qualify for assistance under the Upton proposal, a person would have to live in a state with an approved waiver, have a pre-existing condition and be uninsured because of a failure to maintain “continuous coverage.”
The House Democratic leader, Nancy Pelosi of California, said the money was a pittance, compared with the likely need. “It’s a joke,” she said. “It’s a very sad, deadly joke.”
The latest amendments to the bill amount to “a hoax on pre-existing conditions,” Pelosi said, adding: “If Republicans have their way, Americans with pre-existing conditions will be segregated into high-risk pools where they face soaring costs, worse coverage and restricted care.”