Four reasons GOP ACA replacement failed without a vote

Despite all-out efforts from President Donald Trump and House Speaker Paul Ryan, the Republican’s proposed replacement for the Affordable Care Act (ACA)-the American Health Care Act (AHCA)-failed to proceed to the House for a vote last month, as leaders of the House of Representatives doubted it wouldn’t garner enough votes to pass. So what exactly did House representatives on both sides of the aisle dislike about the bill?

Here’s a look at what MCOs should know.

Reason #1: Fewer Americans would have healthcare coverage.

Persons with health insurance coverage would be reduced by 14 million in 2018, 21 million in 2020, and 24 million in 2026 relative to current law, according to estimates by the Congressional Budget Office (CBO)-which is intended to provide Congress with nonpartisan analyses for economic and budget decisions.

“With midterm elections on the horizon next year, House lawmakers were likely concerned about the consequences of voting for legislation that could result in so many people losing their coverage in such short order,” says Garrett Fenton, JD, member, Miller & Chevalier, a law firm with a specialty in healthcare. “On the other hand, many in the Republican party-and the Trump administration in particular-tried to downplay the numbers by calling into question the CBO's accuracy, and emphasizing that the lack of a mandate to purchase insurance would result in an increase in the uninsured rate due to many individuals simply choosing not to buy coverage.”

Reason #2: Insurance premiums would rise initially.

There was public backlash to the CBO’s projected 15% to 20% increase in premiums over the next two years,” says Arthur Tacchino, JD, chief innovation officer, SyncStream Solutions, a provider of healthcare reporting and compliance solutions. “Many Americans believe that the ACA’s premiums are just too high and unaffordable. The CBO’s projections did little to convince Americans that premiums would go down.” 

This is in spite of the fact that the CBO predicted that by 2026, average premiums for single policyholders in the non-group market under the legislation would be roughly 10% lower than under current law, Fenton says.

Next: Reasons #3 and #4

Reason #3: Premium changes would vary significantly by age.

Under the proposed legislation, insurers would be allowed to generally charge five times more for older enrollees than younger ones rather than three times more as under current law, substantially reducing premiums for young adults and substantially raising premiums for older people, the CBO stated.

Fenton says the goal of this change clearly was to attract younger (and generally healthier) individuals into the risk pool with lower premiums, but the additional flexibility in age rating was a key sticking point for the AARP and other powerful interest groups that opposed the legislation.

Adds Tacchino, “Not only would the legislation have changed the underwriting ratios, but the credits that would be available to Americans would be administered in a way that older citizens would now have much higher premiums. Oftentimes older Americans have a much higher need for healthcare coverage.”

Reason #4: The bill significantly curtailed federal support for Medicaid.

In particular, it allows states to require able-bodied adults to work and would phase out Medicaid expansion. After 2020, states that expanded Medicaid would no longer receive enhanced federal funding to cover low-income adults like they did under the ACA and states that haven't expanded would be immediately barred from doing so.

“These proposed Medicaid changes were some of the most controversial provisions of the AHCA,” Fenton says. “The ability for states to impose work requirements was added to the legislation shortly before the scheduled vote on the House floor, in an effort to attract more conservative House Republicans. But this provision, along with phasing out the Medicaid expansion in general, might have made the bill less attractive for a number of more moderate Republicans, particularly in the 31 states that already expanded Medicaid.”

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