UPDATED: AHCA Off for Now

House Vote Pulled

March 24, 2017, 3 pm CDT ... Word is filtering down that Speaker Paul Ryan has pulled the GOP's ACHA bill from the floor as the leadership couldn't rally enough votes to pass the measure.

Statement from Rep. Jim Cooper:

"I'm glad the House didn't pass this bad bill and hurt people who need healthcare. I think the energy from people back home, including thousands of Tennesseans, made the difference," Rep. Cooper said. "Obamacare isn't perfect. But we should work together to fix the law and make it better for everyone. It will take courage and political will from both parties. I hope Congress is up to the task because voters are watching."

Statement from THA President and CEO Craig Becker:

"The American Health Care Act was pulled from consideration today in the U.S. House of Representatives. We recognize Tennessee's congressional delegation's time and attention to so many of our priorities and appreciate their efforts to address problems in the healthcare system. However, THA feels this legislation was not the solution - our hospitals have very few resources to address any increases in the uninsured. We stand ready to continue working with federal lawmakers on policies that strengthen healthcare and hospitals in the Volunteer State."

House Vote Anticipated

March 24, 2017 ... Sometimes the Art of the Deal is an ultimatum. President Trump signaled he is ready to move on to other priorities and called for a vote on ACHA today. As negotiations continued into the night, essential health benefits were taken off the table to appeal to the House Freedom Caucus, whose votes are critical to passage. However, a number of moderate Republicans are unhappy to lose the mandate that all insurers cover 10 essential health benefits ranging from prescription drugs and maternity/newborn care to hospitalization and mental health/addiction services. It is still unknown whether Speaker Paul Ryan will be able to hit the magic number of votes to get ACHA out of the House and over to the Senate.

March 23, 2017 ... A U.S. House of Representatives vote is anticipated to happen on the evening of March 23. As of 7:45 am CDT, President Trump and House leadership were not anticipated to have the necessary votes to move ACHA through the House. However, negotiations continue to try to pull in a dozen or more 'ayes.' Changes already made to ACHA and those that would likely have to occur today in order to get the necessary House votes could make it more difficult to then get the measure passed in the Senate. Check back for updates.

The vote scheduled for Thursday, March 23 has been delayed as the president and GOP leadership were unable to secure the necessary votes to repeal and replace the ACA.

President Trump Visits Nashville & Releases a Budget

President Donald Trump held a rally in Nashville on Wednesday, March 15 at the Municipal Auditorium. He addressed the latest court action against his latest travel ban calling it a gross act of judicial overreach. While healthcare was on the topic list, the rally speech was short on specifics other than it would be 'great.' Trump, however, did indicate that the current AHCA bill is probably not in its final format and that compromise, change, and negotiation will occur.

In other news, the president also released his budget plan, which greatly increases military spending but cuts deeply in other areas ... including slashing $5.8 billion from National Institutes of Health funding. The deep cuts in research funding would impact the recently passed 21st Century Cures Act, which has broad bipartisan support and was heavily supported by Sen. Lamar Alexander. The new budget, however, must be approved by Congress.

Comments from Senator Bob Corker on AHCA, March 16th:

"I had a discussion on Air Force One yesterday with President Trump about healthcare, and as this bill moves through the House of Representatives, I hope the following issues will be addressed.

• Cost.The bill should help lower the cost of healthcare sooner rather than later.

• Affordability.Tax credits must be sufficient enough to allow hardworking Americans not covered by their employer to reasonably purchase a health care plan that fits their needs.

"I will be watching closely as the legislation progresses."

Comments from Senator Bob Corker on the President's Budget, March 16th:

Corker is chairman of the Senate Foreign Relations Committee and a member of the Senate Budget Committee.

"I sincerely appreciate the Trump administration's effort to cut waste and encourage efficiency, but the fact is that until the president and Congress are willing to address the real drivers of our debt - Medicare and Social Security - we will be complicit in shackling future generations with the financial burden of our own lack of discipline," said Corker. "That is not a legacy I want to leave."

"I truly believe we can solve our mandatory spending problem without harming those currently dependent on these programs, and I have offered numerous legislative proposals toward that end," continued Corker. "I am hopeful that the complete 2018 budget to be delivered in May will include appropriate reforms because until we address this problem head on, discretionary spending will continue to be under severe pressure."

Comments from Rep. Jim Cooper on the President's Budget, March 16th:

"There are many problems with the Trump budget. It hurts our standing abroad, assumes climate change is a myth, puts our local art and music programs in jeopardy, and cuts after-school and affordable housing programs that Nashvillians need. It also omits Trump campaign priorities like jobs and infrastructure spending.

"And it would devastate medical research. NIH has funded more than $3 billion in research in Tennessee in the last decade. That funding helps local researchers who are fighting cancer, Alzheimer's, AIDS, obesity, diabetes and much more. Cutting today's research dollars will hamper tomorrow's treatments and cures.

"But ultimately Congress sets the budget, not the President. I hope the public will help Congress improve the budget so that it won't harm America."

Update with CBO Information:

The nonpartisan Congressional Budget Office (CBO) scored the GOP's American Health Care Act (AHCA), releasing information on Monday, March 13. While the plan is anticipated to reduce the federal deficit by $337 billion over the next decade, the collateral cost is an anticipated 24 million more Americans without insurance by 2026 relative to the current numbers under ACA.

Republican supporters have said the numbers don't accurately reflect the full intention of the AHCA, which has three parts to it. HHS Secretary Tom Price, MD, and others have said when the plan is fully implemented, costs to consumers will come down through a number of measures including the opportunity to purchase insurance across state lines. However, the number of uninsured is anticipated to climb no matter what as more individuals could be uninsured by choice with the repeal of the individual mandate. Critics have said this will likely result in younger, healthier individuals opting out of insurance with older, sicker individuals trying to purchase coverage with the likely effect that policy prices will rise as a result of a higher risk pool of covered lives.

Calling the plan 'TrumpCare,' Democrats have said the CBO report (see link below) highlights the GOP plan falls short of the president's promise of insurance for all.

U.S. Rep. Jim Cooper (TN-05) released the following statement on the nonpartisan Congressional Budget Office's cost estimate of the Republican health care bill on March 13:

"President Trump promised 'insurance for everybody' and Secretary Price said that everybody will get coverage under the Republican plan. More than 20 million people gained insurance under the Affordable Care Act, and we have the lowest uninsured rate in U.S. history," Rep. Cooper said. "But today, the nonpartisan Congressional Budget Office confirmed what health experts already feared - 24 million Americans will lose their health insurance under the Republican health plan. That's not insurance for everybody. Republicans are undoing progress that was made and ruining lives."

Original Text and Reactions to the Introduction of AHCA

House Republicans have introduced their plan to repeal and replace the Affordable Care Act. While many (including us) are still combing through the details of the 123-page draft legislation, reaction is beginning to flow in from a variety of stakeholders. We will continue to update this information as reactions and details become available.

Key components of the act include:

• Allowing adult children to stay on their parents' plan until age 26.
• Doing away with the individual mandate.
• Retaining coverage for pre-existing conditions (but individuals could be charged more for coverage if there's even a short lapse in coverage continuity)
• Sunsetting "essential health benefits" requirement on Dec. 31, 2019.
• Postponing 'Cadillac Tax' until 2025.
• Getting rid of current subsidies to buy health insurance and replacing with capped, refundable tax credits (capped at $14,000/family max with smaller credits based on income over $75,000 individual or $150,000 filing jointly).
• Funding changes for Medicaid - funding for expansion to continue until 2020 with changes thereafter
• Significantly increasing amount individuals and families can contribute to health savings accounts (HSAs) and provides more flexibility in how those dollars are spent.
• Funding for states that can be used to provide financial assistance for high-risk individuals who do not have access to insurance coverage through an employer. Note, the bill stipulates the funding would be during a period from Jan. 1, 2018-Dec. 31, 2026. States may also apply the funding to a number of other approved uses including providing incentives to appropriate entities to enter into arrangements with the state to help stabilize premiums in the individual market, providing payments to providers, or assisting with out-of-pocket costs for individuals.
• Stripping away funding for Planned Parenthood and other 'forbidden entities.'

Click here to view a PDF of the House GOP plan.

Reaction has begun flowing in from various stakeholders:

Craig Becker, President & CEO, Tennessee Hospital Association

"The challenges associated with the Affordable Care Act are no secret and hospitals welcome the development of solutions to our nation's healthcare needs. While introducing some new solutions, the AHCA presents more potential challenges to hospitals.

"Primarily, we believe a significant number of the roughly 230,000 Tennesseans currently covered could lose their coverage because of an inability to pay for insurance due to significantly reduced federal subsidies.

"The proposal includes significant changes to the funding structure for Medicaid and gives more authority to states for operation of such programs. THA views greater state control of our Medicaid program as a potentially positive move, but we see challenges in this new model. It is important to understand the implications of such flexibility and the accompanying increase in financial risk to states under a per capita funding model. We are also concerned about the unknowns of how and at what level the per capita approach will be funded.

"We must ensure Medicaid enrollees continue to receive comprehensive and adequate benefits with fair reimbursement to providers for healthcare services. The current proposal stands to make achieving these goals a major obstacle.

"The bill also fails to sufficiently address the instability of the insurance marketplace for consumers, which THA has identified as a top priority. Tennesseans have seen dramatic changes in the insurance marketplace in our state as multiple insurers have withdrawn their participation in the past two years. This has resulted in limited coverage options for people in many parts of the state at a time when future participation by insurers remains uncertain.

"The current proposal jeopardizes the continuation of access insurance for many Tennesseans, which could further drive up the costs of uncompensated care. Tennessee hospitals each year provide nearly $2 billion in services to the uninsured. When coupled with significant cuts to reimbursement from the ACA - which remain in the AHCA proposal - this presents a dark forecast for the future of hospitals in Tennessee, especially our rural and safety net facilities.

"The complexity of healthcare in America makes crafting a viable and effective solution a difficult task. However, federal lawmakers must find ways to provide healthcare coverage to Americans while ensuring such a solution supports the viability of hospitals and other providers, especially those in rural areas. The livelihood of Tennessee's hospitals and the communities we serve hinges on finding this balance."

U.S. Senator Lamar Alexander

"One especially encouraging aspect of the House bill is that it would help 40,000 Knoxville-area residents who are expected to have no insurance plans available on the exchange next year by allowing them to use their Affordable Care Act subsidy outside of the exchange. The bill also allows subsidies to be used to purchase lower cost health plans than allowed under current law, which would provide relief to Tennesseans facing increased premiums on the Obamacare exchanges across the state. The House begins the committee process on the bill this week, but this bill clearly would provide Americans with a broader choice of plans, rein in the out-of-control Medicaid entitlement spending, and give states flexibility to provide Americans with access to low-cost insurance."

U.S. Senator Bob Corker

"I am appreciative of what appears to be a very constructive contribution by members in the House, and while I am still reviewing the legislation and want to see a Congressional Budget Office cost analysis, this seems to be an important step in the right direction," said Corker. "With rising premiums, lost coverage and fewer choices, it is clear that the Affordable Care Act is not working. I am glad the process is underway to put in place an alternative that works better for the American people."

U.S. Representative Jim Cooper

"This entire process has been conducted in secret. Calling for a vote on a bill that nobody has seen is akin to martial law. Plus, no one knows how much the bill would cost.

"What we do know is this doesn't replace Obamacare, and it doesn't make improvements either. The Republican bill makes insurance more expensive and takes insurance away from people who need it the most. In its place, insurance executives making $500,000 get a tax break.

"The Republican bill does nothing to control costs; nothing to combat high drug prices; and nothing to get every American covered. In an especially cruel turn, Republicans would force state Medicaid programs for the poorest people to either foot a bill they can't afford or cut enrollees."

• The AMA has long supported advanceable, refundable tax credits as a preferred method for assisting individuals in obtaining private health coverage. It is important, however, that available credits be sufficient for quality coverage. The AMA is concerned that by relating credits to age - rather than inversely related to income - the AHCA will result in greater numbers of uninsured Americans.
• The AMA is concerned with the proposed rollback of Medicaid expansions, which have been highly successful in providing coverage for lower income individuals. The AMA is also concerned that changes to Medicaid could limit states' ability to respond to changes in demand for services, including mental health and substance abuse treatment as a result of the ongoing crisis of opioid abuse and addiction.
• The AMA cannot support provisions of the legislation that repeal the Prevention and Public Health Fund or that eliminate the ability of patients to receive their care from qualified providers of their choice.
• The AMA does not support provisions targeting, in this specific case, affiliates of the Planned Parenthood Federation of America. Provider choice is an important element of a reformed health care system, and the AMA cannot support the precedent of restricting access to otherwise qualified providers of care for covered services.

House Speaker Paul Ryan:

"Obamacare is rapidly collapsing. Skyrocketing premiums, soaring deductibles, and dwindling choices are not what the people were promised seven years ago. It's time to turn a page and rescue our health care system from this disastrous law. The American Health Care Act is a plan to drive down costs, encourage competition, and give every American access to quality, affordable health insurance. It protects young adults, patients with pre-existing conditions, and provides a stable transition so that no one has the rug pulled out from under them.

"Working together, this unified Republican government will deliver relief and peace of mind to the millions of Americans suffering under Obamacare. This will proceed through a transparent process of regular order in full view of the public. I want to thank all of our members who have contributed their ideas, especially Chairman Walden and Chairman Brady, as well as Secretary Price and the Trump administration, for their commitment to keep this promise and get this right."

S&P Global Ratings:

On March 6, 2017, the majority Republican caucus in U.S. House of Representatives unveiled their proposed replacement for the landmark 2010 Patient Protection and Affordable Care Act. The draft American Health Care Act legislation is consistent with the thrust of what S&P Global Ratings said about the likely direction of Medicaid policy in its November 2016 commentary, "Medicaid's Status As An Open-Ended Entitlement Is On Life Support Following The Election."

In our view, the proposed change to federal funding to states for Medicaid would result in fiscal strain that would increase over time. Also, by freezing the eligibility of the Medicaid expansion population, states could confront the difficult policy choice of either eliminating coverage for that population or providing it without federal matching funds. Ultimately, we believe it's difficult to overstate the importance of Medicaid to state finances and credit quality. Medicaid is both a health insurance program and a mechanism for delivering aid to U.S. states during recessions, and it sits at the heart of the federal-state fiscal relationship/

In general, the proposal picks up on one of the two main options we described in our November commentary, per capita allotments. Grant amounts would be sized differently according to five categories of enrollees (children, elderly, blind and disabled, previously eligible adults, and expansion population adults). For states, we wrote that this path was probably more favorable from a fiscal standpoint than fixed block grants because federal funding would increase with enrollments, such as during recessions. Grant amounts would grow at medical inflation CPI plus one percentage point. Under this formulation, federal subsidies to the states would grow at a faster rate than regular CPI but probably would not keep pace with program cost growth. It would not account for the growth of costs for new and oftentimes expensive treatments. Indeed, among the objectives as stated by congressional leaders is to realize federal fiscal savings vis-à-vis the Medicaid program.

Finally, the plan would continue to provide full funding for the Medicaid expansion population through 2020. After 2020 it would also continue to provide the same federal funding subsidy rate (90%) for those that remained continually enrolled. No new enrolled person would be matched with federal funding, however, and any lapse in enrollment would disqualify the individual from re-enrollment (at least with federal matching funds). Income and employment status among the Medicaid population is known to fluctuate so we expect the continuous enrollment requirement would have the effect of causing enrollments to decline. In short the Medicaid expansion plan would enter a "run-off" mode with the number of enrollees expected to decline over time. States would also be required to re-determine enrollee eligibility every six months, likely accelerating the declining enrollments that would ensue under the legislation.

National Education Association President Lily Eskelsen Garcia

"It's time for the Republican leadership to come clean with the American people. Repealing the ACA will harm our students and their families by forcing cuts to critical programs, reducing financial support for lower-income Americans, and taxing the middle class. Bottom line, working Americans will pay more for less coverage while insurance executives and the wealthy get handouts.

"The ACA expanded coverage to more than 20 million previously uninsured Americans, dramatically reducing the number of uninsured children in this country. The Republican leadership plan will reverse those gains, leading millions to potentially lose coverage while making drastic cuts in Medicaid funding, benefits, and eligible beneficiaries, and forcing some states to consider diverting money from education to health care.

"Medicaid's support for school-based health services will also suffer under the Republican leadership plan. Mental health care, vision and hearing screenings, diabetes and asthma management are just some of what school children stand to lose.

"We will continue to defend the ACA and Medicaid, our country's health care safety nets, and quality, affordable coverage for children and working families. It's time for Congress to do the same and look out for students and ordinary Americans."

Statement by President Chris Shelton, Communications Workers of America

"We're still learning about the health care plan proposed by House Republicans. It's clear, however, that the legislation provides a big tax giveaway to corporations and the 1 percent, while working families, seniors and children are stuck picking up the tab.

We can all agree that the American healthcare system must be improved.

But this House proposal would strip away coverage from millions of working families who need it most, and hand millions of dollars in tax breaks and handouts to insurance companies, other corporations and the wealthy.

Lower income working families, those earning around $30,000 a year, would lose the tax credits they now receive that make it possible for them to pay for premiums, deductibles and out-of-pocket costs.

Workers age 50 and older would take a big hit, because insurance companies would be permitted to charge them five times as much as younger workers.

The plan rewards the 1 percent who earn more than $774,000 a year with a big tax cut, around $33,000 according to the Tax Policy Center. The richest of the rich, the top one-tenth of 1 percent, would get an average tax cut of $197,000. Insurance, drug and medical-device companies also get tax breaks, and insurance company CEOs get an additional tax benefit.

These tax breaks for corporations and the wealthy are estimated at $525 billion over 10 years. This isn't a health care plan, it's a shameful handout to corporations paid for by working families who will pay more for less coverage, and by those Americans who will be left with no health care coverage at all."