Robert Doherty, the long-time chief lobbyist of the American College of Physicians, has drawn attention for his outspoken criticism of the House Republican legislation to repeal and replace the Affordable Care Act. Doherty is senior vice president for government affairs at the Philadelphia-based ACP, which represents 148,000 internists and internal medical subspecialists. He spoke with Modern Healthcare senior reporter Harris Meyer on May 4, minutes after the House passed the American Health Care Act or AHCA. He described his organization's objections to the House bill and its plans to lobby the Senate to preserve the ACA's insurance coverage expansions. The following is an edited transcript.
Modern Healthcare: What's your immediate response to the House passage of the AHCA?
Robert Doherty: It's premature for the Republicans to take a victory lap on their healthcare bill. It's not victory for patients at all. It rolls back coverage for millions of people. Getting legislation like this through the Senate will be tough sledding.
House Republicans disregarded views of physicians, nurses and other front-line providers to pass this terrible legislation. We have sent a letter to the senators asking them to put aside this flawed bill and start over on bipartisan reforms to improve rather than harm patient care.
MH: Did you try to work with House Republicans on the bill?
Doherty: Going back to January, we said we'd love to have a conversation about improving the ACA, which is not a perfect bill by any means. We got no response. There was absolutely no effort to engage with us and other groups representing front-line clinicians. The Republicans were so dead-set on repealing the ACA that they weren't willing to have a conversation about improving it.
MH: What are the AHCA provisions that most concern your organization?
Doherty: It's hard to tease out one because the whole bill is so awful for patient care. At the top of the list is the damage it does to Medicaid. If the feds cut their contribution by 25%, the only way states can make up for that is by reducing eligibility and benefits, raising taxes, cutting provider payments or cutting other programs. The bill also phases out the Medicaid expansion. Without the higher federal contribution, the vast majority of expansion states will have no choice but to end the program. That's unacceptable. It guts the ACA's consumer protections in terms of pre-existing conditions and essential health benefits. Insurers might no longer be required to cover chemotherapy or childbirth or substance abuse treatment or physician and hospital visits or prescription drugs. Insurers could base premiums on pre-existing conditions, and that would make coverage unaffordable. The bill provides some funding that states could use for high-risk pools, but all the analysis we've seen is that the dollars don't come close to providing affordable coverage for those with pre-existing conditions. The bill replaces income-based premium and cost-sharing subsidies with age-based ones. It's less helpful to low-income people and more helpful to high-income people, and poorer people are the ones who most need the help. When you combine that with allowing insurers to charge older people five times more rather than three times more, it will make premiums and deductibles much more unaffordable.
MH: What are the prospects for Senate passage of the House bill?
Doherty: Quite a few Republican senators have gone on record saying they have substantial concerns about the House bill. You'll see particular concerns among senators from Medicaid expansion states who don't want the expansion money cut off. Quite a few Republicans are receptive to a dialogue on how to fix the ACA rather than throwing it out. Those are the folks we'll try to address.
MH: What are the chances of Senate Republicans working with Democrats on a bill?
Doherty: They'll start out trying to do it through budget reconciliation, without any Democratic votes, but they're going to face procedural problems because under reconciliation, provisions must have a direct impact on federal spending, and some of the House provisions on pre-existing conditions and essential health benefits may well be ruled out by the Senate parliamentarian under reconciliation. If Senate Republicans can't get 51 senators to vote for their reconciliation bill, they'll have no alternative other than to reach out to Democrats, or else they'll have to let the whole effort falter.
MH: Is the ACP concerned that its' strong position on the House GOP bill could anger the Trump administration and congressional Republicans and hurt its efforts in other areas?
Doherty: Obviously, we all weigh that if you take a firm stance against what the current administration and current congressional leadership want to do, there can be adverse consequences for your organization on other issues. The physician leadership of ACP made it very clear that rolling back coverage for millions of people is wrong on its merits and wrong morally. They've been very supportive of the firm stance we've taken. We're willing to take the hits that come with that. It doesn't mean that we can't work with the administration on other issues. We're already having side conversations on electronic health records and other issues that are very productive.
MH: Do you see anything unique about this Republican repeal-and-replace effort?
Doherty: In my 38 years of advocating for physicians and patients, I've never seen a bill that would do more harm than this one. Historically, almost every action relating to healthcare has been to expand access, such as Medicare, Medicaid, CHIP, and the ACA. I've never seen legislation get this far to take access and coverage away from people.
MH: Do you expect Republicans to face political repercussions?
Doherty: I expect there will be political consequences. If you start taking coverage away from people, such as from children born with heart defects, those stories get known and there will be tremendous backlash. The Republicans who voted for this will get an earful, and they should.