Agenda for the 115th Congress: Focus on the ACA

from Family Voices, Ntl:

On January 3, the members of the new Congress were sworn into office and the 115^thCongress convened for the first of its two, year-long sessions. This Congress includes 53 new Representatives and seven new Senators. Republicans control both chambers, with a 52-48 majority in the Senate and a 241-194 majority in the House.

2017 Agenda

The president-elect and Republican congressional leaders have made repeal of the Affordable Care Act (ACA, or "Obamacare") a top priority for Congress (more below). They have also announced their intention to drastically alter the nature of the Medicaid program by turning it into a block grant or capping federal payments on a per-beneficiary basis. At the end of this fiscal year (September 30, 2017), funding for the Children's Health Insurance Program (CHIP) will expire, as will authorization and funding for the Maternal, Infant and Early Education Home Visiting (MIECHV) program, and Family-to-Family Health Information Centers (F2Fs). Family Voices and other advocates will be working hard to ensure continuation of these programs, to combat structural changes to the Medicaid program, to fight ACA repeal if there is no suitable replacement, and to ensure adequate funding for appropriated programs such as the Maternal and Child Health Block Grant.

ACA Repeal

ACA repeal would be a two-step process. First, both the House and Senate would pass a joint "budget resolution" (which is not signed by the president). This would allow them to take up a "reconciliation" bill that, if enacted, would repeal parts of the ACA, most likely with a delayed effective date so that a replacement can be developed. This is being called the "repeal-and-delay" strategy. Both the budget resolution and reconciliation bill have a special status in the Senate requiring only 51 votes for approval, rather than the 60 votes usually needed to advance legislation to which any Senator objects.

This week - most likely late Wednesday night (early Thursday morning) - the Senate is expected to vote on the budget resolution. The resolution is expected to pass, although only two Republican Senators need to join the Democrats and Independents in voting NO for the budget resolution to fail. (There are 52 Republicans in the Senate; Vice-President Biden can vote to break a tie.) Some of the Senators who have expressed reservations about repealing the ACA without a simultaneous replacement are Senators Lisa Murkowski (AK); Tom Cotton (AR); Jeff Flake and John McCain (AZ); Cory Gardner (CO); Rand Paul (KY); Susan Collins (ME); Rob Portman (OH); Patrick Toomey (PA); Lamar Alexander  and Bob Corker (TN); and Shelley Moore Capito (WV). Once approved by the Senate, the House would approve the resolution.

If adopted by the House and Senate, the budget resolution will direct certain committees in each body to develop legislation to "reconcile" the law with the resolution's budget targets. The committees' legislation would then be combined into a "reconciliation" bill that would effectively repeal the parts of the ACA that have a significant budgetary impact - the individual and employer mandates, the premium tax credit, cost-sharing subsidies, and the Medicaid expansion. The reconciliation bill is likely to delay the repeal of fundamental parts of the ACA (such as premium subsidies) for two to four years, a matter still being debated among Republicans. But, some provisions might go into effect immediately, including a repeal of the maintenance-of-effort (MOE) provision requiring states to maintain their eligibility and enrollment policies for children under Medicaid/CHIP, which could result in loss of coverage for millions of children, according to an Urban Institute analysis. On Tuesday, House Speaker Paul Ryan (R-WI) said that some elements required to replace the ACA could be included in the repeal bill, although he did not go into specifics.

 

Significantly, Senate rules may prohibit the use of a reconciliation bill to repeal some of the ACA's consumer protections, since they are not primarily budgetary in nature, such as the ban on pre-existing condition exclusions and coverage caps and the provision allowing children to stay on parents' health plans until they are 26. But, there are no black and white rules about this; it will be up to the Senate parliamentarian to decide.

 

Even with a delay in the repeal date, many analysts expect that an impending repeal will cause many insurers to drop out of the marketplaces, thus causing significant premium increases that could leave millions of Americans without access to affordable health insurance, even before the repeal goes into effect. In fact, the American Academy of Actuaries sent a letter to House leaders explaining that a repeal of the ACA's individual mandate and enrollee subsidies, without enacting a replacement at the same time, could result in significant market disruption, leading to millions of Americans losing their health insurance. Hospital groups and the insurance lobby have also expressed concern about ACA repeal, even a delayed one. The Urban Institute has estimated that the effects on the insurance market could result in loss of health insurance for 30 million people by 2019 if the ACA's individual mandate and insurance subsidies are repealed without repealing the law's consumer protections (such as guaranteed issue to those with pre-existing conditions).

 

A number of consumer groups have formed the "Protect Our Care Coalition," whose members include Families USA, the Service Employees International Union, MomsRising, the NAACP, and the National Council of La Raza. The coalition plans to educate the public on the potential harms of repealing the ACA "without simultaneously voting on a plan that guarantees people will have health and financial security."

ACA Replacement

Rep. Tom Price, MD (R-GA), the nominee for Secretary of Health and Human Services, previously developed legislation to replace the ACA. Senator Rand Paul (R-KY) recently announced that he is developing replacement legislation as well. House Speaker Paul Ryan (R-WI) and the president-elect have outlined replacement ideas (but not developed legislative language), such as allowing insurance to be sold across state lines and establishing high-risk pools for individuals with expensive medical conditions. House Majority Leader Kevin McCarthy (R-CA), along with the Republican chairs of House committees with jurisdiction over health matters (the Committees on Ways and Mean, Energy and Commerce, and Education and the Workforce), sent a letter on December 2to the governors and insurance commissioners of all the states asking them for input on developing an ACA alternative and posing nine specific questions. Responses were requested by January 6.