AHCA next steps: 4 things MCOs should know

On May 4, the House passed legislation that would replace the Affordable Care Act (ACA) by voting 217 to 213 in support of the revised American Health Care Act (AHCA). No Democrats voted for the bill, and 20 Republications voted against it.

So what are the next steps for the bill, and how likely is it that it will become law? Here’s are four things MCOs should know.

1. The Senate may take several weeks or even months to vote on the bill.

Senate procedural rules favor more debate than House rules, which will stretch out the time it takes for a vote. “The Senate will need time to reach consensus on complex issues,” says Harry Nelson, a healthcare attorney with Nelson Hardiman LLP and author of “From ObamaCare to TrumpCare.” “Republican senators whose states expanded Medicaid are at odds with senators whose states refused expansion funds. Issues like protecting low-income seniors and funding state high-risk pools will also take time to debate.”

Garrett Fenton, JD, member, Miller & Chevalier, a law firm with a specialty in healthcare, points out that the Senate needs to wait until the nonpartisan Congressional Budget Office issues an updated report (or score) on the estimated impact of the AHCA (including the most recently-adopted amendments) on the federal budget and rate of uninsured individuals. The updated score is not expected to be published until May 22 at the earliest.

2. Senators will likely require some changes to the current AHCA.

The narrower Republican majority and the voting power of more moderate Republican senators, including those from states that expanded Medicaid, will likely lead to a more liberal bill that offers more protection of individuals with preexisting conditions and less reduction of Medicaid funding, Nelson says.

Fenton says some Senators have expressed concerns with various AHCA provisions, including waivers that would allow states to redefine the essential health benefits that individual and small group market plans generally must cover (and upon which all plans must not impose annual or lifetime dollar limits), permit insurers to rate individuals based on their health status, and allow insurers to charge older enrollees more than their younger counterparts-by an even greater factor than 5:1 (which the AHCA already purports to increase from the 3:1 maximum factor currently allowed under the ACA).

In addition, some Senate Republicans are concerned about the AHCA's phasing out of the ACA's Medicaid expansion and transition to a "per capita cap" system, defunding of Planned Parenthood, and structuring the new tax credit system for individual market coverage, Fenton says. A 13-member Republican Senate healthcare working group has formed to work out the details of the forthcoming bill.

Fenton also notes that from a procedural standpoint, the legislation may need to be modified in order to comport with the Senate's budget reconciliation rules. “The House is not subject to the same rules, so some of the current AHCA provisions that ultimately helped gain the support of many House Republicans may be at risk of being removed or drastically modified in the Senate,” he says.

Next: Will the Senate pass a revised bill?

3. The Senate might pass a revised bill.

Nelson believes the Senate will likely pass a bill, but it will have substantial differences from the House bill. “Passage is a political necessity because Republicans will have ‘egg on their face’ for not making good on their promise to ‘repeal and replace’ the ACA after seven years, and also because Republicans share the overriding goals of delegating power to the states to set insurance rules and pass a tax reform bill later in the year,” he says.

Fenton believes that the Senate could pass its own version of legislation. “But will House Republicans maintain their already razor-thin support for the AHCA once Senate changes are made?” he asks.

4. If the Senate passes the bill and President Trump signs it into law, some provisions could be effective right away.

Fenton says that some provisions of the House-passed AHCA would take effect immediately, and even retroactively in some cases (e.g., individual and employer mandates would be repealed as of January 1, 2016, and the annual fee on health insurers would be repealed effective January 1, 2017). Some provisions repealing certain ACA taxes and expanding health savings accounts would become law as soon as 2018, while other AHCA repeals and modifications (and potential state waivers) of certain market reforms would take effect beginning in 2020, and still other provisions would be delayed further (e.g., the Cadillac tax would not take effect until 2026, rather than 2020 as under current law).

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.