Hospital groups and some health insurers are lobbying hard to convince House Republicans to drop their current drive to repeal and replace the Affordable Care Act, warning of dire harms to patients and the healthcare industry.
Opponents of the American Health Care Act claim the House GOP bill's provisions could unravel protections for people with pre-existing conditions, roll back the ACA's Medicaid expansion, leave millions more Americans uninsured, and significantly reduce overall Medicaid spending through per-capita growth caps. Nevertheless, President Donald Trump and House GOP leaders are pressing for a House vote on the bill this week, because the House is scheduled to take a weeklong recess starting Thursday.
The revised bill includes controversial new provisions, supported by House ultra-conservatives, that would let states obtain waivers from key ACA insurance rules requiring plans to cover 10 minimum essential health benefits, barring insurers' use of pre-existing condition screening and limiting how much insurers can vary premiums based on age.
Those waivers would not apply to members of Congress who buy coverage through the ACA exchanges. They would keep the ACA protections.
"Our concern is that these waivers will return the individual insurance market to the Wild West," said Meg Murray, CEO of the Association for Community-Affiliated Plans, which represents safety-net health plans. "Right now, with the opioid epidemic, it makes no sense to allow states to roll back mental health and substance abuse coverage."
"In talking to our delegation, they understand the bill's impact on eroding the Medicaid expansion and the long-term impact of per-capital caps," said Betsy Ryan, CEO of the New Jersey Hospital Association, who believes three of the state's five Republican congressmen will vote no. "But we're not there yet. We're not at the turning point until this thing is done."
The pressure from industry associations, patient advocacy groups and constituents appears to be having an effect. As of Tuesday morning, House GOP leaders remained uncertain whether they have the 218 votes needed to pass their amended AHCA. About 20 House Republicans—most of them considered moderates—have publicly stated their opposition to the latest iteration of the bill, and a sizable number of others reportedly are undecided. No Democrats are supporting it.
Some Republicans coming out against the bill cite its weakening of protections for people with pre-existing medical conditions. "I've supported the practice of not allowing pre-existing illnesses to be discriminated against from the very get-go," Rep. Fred Upton (R-Mich.), an influential House veteran, said on a Michigan radio show Tuesday. "This amendment torpedoes that, and I told leadership I cannot support this bill with this provision in it."
The uncertainty about House Republican support for the bill is particularly intense in states such as California, New Jersey, New York and Pennsylvania, where many GOP congressmen face re-election contests next year in districts carried by Democratic presidential candidate Hillary Clinton in 2016.
Hospital leaders in those states are pushing lawmakers hard to reject the bill. They warn that their states might not be able to afford to continue the Medicaid expansion if enhanced federal funding ends. And they caution that even though their states currently are unlikely to apply for ACA waivers on insurance rules, it's better to have strong protections in place at both the federal and state levels for people who are older and have pre-existing conditions.
The Healthcare Association of New York State ran a newspaper ad in the northern New York district of Republican Rep. Elise Stefanik, urging her to oppose the legislation. The ad warns that the bill jeopardizes coverage for 2.8 million New Yorkers, cuts Medicaid funding for aged and disabled people and puts affordable coverage for older and sicker people at risk.
New York is at particular risk under the bill because state law requires all health plans to cover abortions. Under the House GOP bill, people buying individual-market plans that cover abortions would not be eligible to receive premium tax credits to help them afford insurance. Of New York's nine House Republicans, just two—Dan Donovan and John Katko—have publicly announced their opposition to the bill.
"Our key message to lawmakers is preserving meaningful coverage for preventive services and chronic conditions, making it more affordable to treat conditions appropriately," said Susan Van Meter, the New York association's senior vice president of federal relations.
The Hospital and Healthsystem Association of Pennsylvania is telling members of the state's Republican delegation that the Medicaid expansion is critical to hospitals' financial health, and that the proposed waivers from ACA insurance requirements and the proposal to set up state high-risk pools pose major challenges.
Four Pennsylvania Republicans have publicly stated their opposition to the AHCA, and others are wavering. "I'd love to be a fly on the wall in rooms with some of these folks," said Scott Bishop, senior vice president for legislative advocacy at the Hospital and Healthsystem Association of Pennsylvania.
Insurers are less unified than hospitals in their stance on the AHCA. America's Health Insurance Plans, the biggest health insurance trade group, isn't taking a position on the GOP bill. Still, it's pushing for the bill's repeal of the ACA tax on health insurance premiums, which it argues drives up rates for consumers.
The Association for Community-Affiliated Plans' Murray warned that the House GOP bill would lead to a race to the bottom. If states were allowed to waive the ACA's insurance rules, healthier people would seek to buy cheaper, bare-bones plans, and premiums for people who needed more robust benefits would spike. "It's a nonvirtuous cycle," she said.
Tom Policelli, CEO of the not-for-profit Minuteman Health system, which serves Massachusetts and New Hampshire, also isn't supportive of the House GOP bill. But that's not because he particularly likes the Affordable Care Act.
"The entire debate is a little frustrating," he said. "I don't think the Republican bill addresses the real problems out there, and it may create new ones. The AHCA would create uncertainty, and if I were king for a day, I wouldn't introduce new uncertainties."
The real problems policymakers need to fix are the ACA's risk adjustment system and its requirement that health plans must pay out a certain percentage of premium revenue for medical costs, Policelli said. Those flawed rules are driving up premiums and destabilizing the market. But neither Republicans nor Democrats have shown willingness to address those issues.
Many hospital leaders opposed to the AHCA now worry that some moderate Republicans leery of the AHCA are urging their colleagues to pass the bill so the Senate can fix it.
Meanwhile, some Republican senators, such as Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, are cautioning their House colleagues not to count on that. "I don't think we have a very clear way forward," Graham told CNN.
Healthcare industry lobbyists say they don't know whether the bill will succeed or fail in the House, but they vow to lobby nonstop until the battle is over.
"It's so critical, it's the issue of my lifetime," said Ryan, the New Jersey Hospital Association CEO.
