Although House Republican leadership won over some reluctant members to pass their Obamacare replacement bill, their victory Thursday is unlikely to be the final word. Several Republican senators have already said they want changes to the proposal to make it palatable to their slim majority.
Democrat lawmakers, protestors at Capitol Hill and several hospital and healthcare organizations railed against the American Health Care Act after it passed 217-213 in the House on Thursday afternoon, saying it will make premiums more expensive for older customers and withdraw hundreds of millions of dollars from Medicaid.
But Democrats and outside detractors aren't the bill's biggest hurdle to replacing Obama's signature Affordable Care Act. If substantial changes are made to Medicaid provisions and premium subsidies, the bill could lose enough conservative votes that it can't pass without Democratic support.
Sen. Rob Portman (R-Ohio) wants to soften the AHCA termination of the Medicaid expansion, though his office said Thursday they can't give details on what he's proposing.
America's Health Insurance Plans, the primary health insurers' lobby, reacted Thursday afternoon to the vote by saying the Senate needs to change the House's tax credit approach. House Speaker Paul Ryan's bill goes from a premium subsidy that takes into account age, local market prices and income to one that varies only by age.
For customers like Mark McWhinney, 59, of Kent, Conn., that would mean a significant hike in prices. McWhinney currently pays $135 a month for his plan, as he is semi-retired as a self-employed education consultant. He likes his flexible schedule so he can take care of his 81-year-old mother.
His subsidies now are worth $6,250, and would be higher if premiums were to climb and his income stayed in the low- to mid-$30,000s. But under AHCA, his premium support would be $4,000.
"I could do it. It just would be painful," McWhinney said. But he said he's furious on behalf people who are juggling two part-time jobs and can't adjust like he can.
AHIP, though it expressed it without rancor, says the Senate should retain the current rules of adjusting customers' costs by income, market prices and age.
That idea could gain traction in the Senate, even with a Republican senator who's not a moderate. Sen. John Thune (R-S.D.) told Axios that he'd like to preserve income- and age-based subsidies for customers below 250% of the poverty line.
It's not just people who benefit directly from the ACA who are angry about its repeal.
Andrea Walker, of Arlington, Va., was one of a few hundred protesters who rallied outside the Capitol building Thursday at noon, trying to convince House Republicans that their path was immoral.
Walker, who is on Medicare, had written a homemade sign that said: "What about the CBO 24 million?"
The Congressional Budget Office, which lawmakers rely on for nonpartisan analysis, said that 24 million fewer people would be insured as a result of an earlier draft of the AHCA. The vote Thursday was taken before the CBO had a chance to re-evaluate the amendment that gives states the option of eliminating pricing protections as long as they establish high-risk pools.
Before the vote, some Democrats on the floor yelled: "Where's the score?"
Most of the rise in the uninsured population would stem from states cutting back on Medicaid expansions, or choosing never to implement them. Those elements of the bill did not change over the last six weeks. However, some individuals would lose coverage when their employers stop offering plans after the AHCA eliminates ACA penalties. That, coupled with the bill's less generous subsidies for many, caused the CBO to calculate a net loss in individual customers.
Walker said she can't believe nobody's talking about the fact that the fixes made to woo moderate Republicans don't change what's happening to Medicaid. "I get crazy! That number has not gone away. Why is it OK to vote against these people now, and not six weeks ago?"
AHIP said if Medicaid eligibility criteria change, "we need to give people more time to adjust—and more time for the individual market to stabilize."
Aetna CEO Mark Bertolini said in an interview on Bloomberg TV this week that the AHCA passing the House is a serious step, "but then the next question is what can be done in the Senate?"
He believes much of AHCA cannot survive the procedural hurdles in the Senate that would allow a party-line vote. "Sooner or later, we're going to need a bipartisan solution to make it work for all Americans," he said.
Scripps Health CEO Chris Van Gorder said the bill will be modified significantly in order to pass the Senate. "My reaction to this is sadness not so much because of this vote but mostly because this is just one more example of our elected officials refusing to compromise and work together for the good of the country," he said. "As I have said many times over many years—healthcare should not be political—it's personal, it's about life and death."
Before the House vote, moderate Republican Sen. Lindsey Graham of Sourth Carolina tweeted that a bill that had not been scored and given little debate should be viewed with caution. He also said that he would carefully review the AHCA to ensure that if it becomes law, it would be beneficial to South Carolinians.
"I believe it may take Obamacare's collapse before the parties are willing to work together in a bipartisan manner," Graham tweeted.
Stock investors seemed to discount the possibility that millions would leave Medicaid, potentially leaving hospitals and physicians on the hook for more uncompensated care. After starting the day mostly in the red, HCA Holdings' share price jumped to a gain of 1% at 3 p.m., minutes after the vote. Tenet Healthcare Corp.'s shares also roared to life after starting the day down. Its shares traded up 3%. Community Health Systems saw its shares climb 1% by 3 p.m. They are the three largest investor-owned hospital companies.
The will-they-or-won't-they games the administration has played around cost-sharing reductions are the biggest problem insurers who sell on the exchanges cite as a reason to leave.
For instance, Medica, the last statewide Iowa insurer, said if cost-sharing reductions are not paid, they may well leave the market in 2018. House Speaker Paul Ryan, whose lawsuit first put the cost-sharing reduction payments in jeopardy, pointed to Medica's hesitancy about staying in Iowa as proof that Obamacare is "a failed experiment" and that Republicans must act now to replace it.
Several Republican House members waited until the final seconds of the five-minute voting period to commit to repeal. Thousands have called congressional offices over the last few months to voice their opposition to the AHCA, and many Republican representatives have faced angry crowds of constituents over the bill.
After the vote, a remnant of the protestors chanted, "Shame on you!" and "2018!"
In an unusual breach of decorum, House Democrats began singing after the yes votes were posted: "Na-na-na-na, na-na-na-na, hey, hey goodbye."
