Congress Continues to Debate How to Repeal and Replace the Affordable Care Act

Congress Continues to Debate How to Repeal and Replace the Affordable Care Act

The US House of Representatives has delayed its expected March 23rd vote on the American Health Care Act (AHCA), the replacement bill for the Affordable Care Act, also known as ACA or Obamacare. The House was expected to vote in the evening today, March 24th, but Republican leadership chose to pull the legislation in the final moments. "We came really close today," House Speaker Paul Ryan (R-WI) said at a press conference Friday afternoon, "but we came up short."

The proposed replacement legislation would keep some provisions of the ACA, but there are also some significant differences.

Among the holdovers are the policy on preexisting conditions and the prohibitions on annual and lifetime limits. These clauses are considered especially important for patients with cancer. Also among the items being kept are dependent coverage until age 26 and essential health benefits.

Chris Hansen, president of the American Cancer Society Cancer Action Network (ACS CAN), in a statement, praised the retention of those policies. He went on to state, “However, these protections are hollow if patients and survivors can’t afford insurance that covers the healthcare services they need to treat their cancer diagnosis.”

Eliminated entirely in the proposed legislation are the individual and employer mandates, as well as the cost-sharing subsidy. Instead, a tax credit will be distributed by age (not income as in Obamacare) for Americans earning up to $75,000 per year. For those under the age of 30, a subsidy of $2000 will be given. For those over the age of 60, there will be a subsidy of $4000.

Additionally, the amount individuals can put into health savings accounts would be higher under the new bill.

The revised version of the bill also aims to remove the “essential benefits” provision included in ACA. This measure requires that insurers cover 10 “essential healh benefits” in all policies. One of the essential benefits named is “preventive services” — such as cancer screenings and mammograms. Without the provision, customers may have to pay more in order for such services to be covered by their health insurance, while those who deem such services unnecessary might be able to pay less.

Another significant proposed change in the replacement legislation involves the price ratios for charges to individuals based on age. Under the ACA, insurers are not allowed to charge older subscribers more than 3 times the prices given to the youngest. However, the new AHCA would allow insurance carriers the ability to change this ratio to 5:1 and would extend to states the option of setting their own ratios.

Proposed legislative changes to Medicaid also impact cancer care costs. The bill would shift Medicaid from an open-ended entitlement system to block grants or per-capita caps on states that expanded Medicaid under ACA, based on 2016 reimbursement levels. Non-expansion states would have access to a Medicaid safety supplemental, which consists of a total of $10 billion over 5 years.

In his statement, Hansen pointed out that, “In 2015, approximately 1.5 million people with a history of cancer between 18-64 years old relied on Medicaid for their insurance. Nearly one-third of childhood cancer patients are insured through Medicaid at the time of diagnosis. The proposed repeal of Medicaid expansion along with significant federal funding changes could leave the nation’s lowest income cancer patients without access to preventive, curative, and follow-up health care.”

According to the Kaiser Family Foundation, those who will be most negatively affected by the new policy would be older, low-income Americans in high-cost areas, such as more rural districts. Those Americans without access to many resources will be pressed to cover the gap between the tax credit offered and the cost of insurance coverage—a deficit that could amount up to several thousand dollars.

In its scoring of the AHCA, the Congressional Budget Office (CBO) estimated that 24 million fewer people will have health insurance coverage by 2026. Additionally, they calculated a cut of $880 billion over 10 years to Medicaid. CBO also estimated that the bill would reduce federal deficits by $150 billion over the 2017-2026 (prior to amendements made to the bill, the reduction was estimated to be $337 billion over the 10 years), with the largest savings to come from reduced outlays for Medicaid and elimination of the ACA subsidies.

When CBO released its report, Senator Susan Collins (R-ME), said in a statement that, “The CBO’s estimate that millions of Americans could lose their health insurance is cause for alarm. It should prompt the House to slow down and reconsider certain provisions of the bill.

“This is an extremely important debate with significant implications for millions of Americans,” she continued. We need to spend the time necessary to get this right.”

There is a broad consensus that the current ACA needs reform and that the high cost of deductibles and copays in the health exchanges poses a barrier to oncology care. As breast cancer survivor Kathy LaTour noted in her recent blog, “The ACA has not removed all the financial issues for cancer patients, but it has made a good start. It needs tweaking, we all agree, as the premiums have continued to rise.”

US Health and Human Services Secretary Tom Price, a physician himself, has championed the proposed flexibility and choice that underpins the House replacement legislation:

“The doctor—patient relationship is the most sacred part of our entire healthcare system. The personal stories we heard today are further evidence that under the current healthcare law, that relationship is being undermined. The Affordable Care Act has given Washington more power and authority over healthcare, leaving patients and providers with less freedom over medical decisions. Whenever the federal government thinks it knows better than a patient and their doctor about what they need, quality of care is compromised.”

The bill requires 216 yes votes to pass and move on to the Senate. With no Democrats pledging their support and a total of 237 Republicans in the House, this means that only 21 Republicans can vote “no” and still pass the bill. The effort to secure enough Republican support is ongoing and necessitated the delay in the March 23rd vote, as well as the second delay today, March 24th.