H.R. 1628 chaos raises odds for ACA survival

Process

The Republicans hold just 237 seats in the House and expect to need 216 votes to pass H.R. 1628 there.

Republicans hold 52 seats in the Senate. Under traditional Senate rules, they need 51 votes there to pass a “budget reconciliation” measure, and 60 votes to pass an ordinary bill. The Senate parliamentarian, an obscure advisor hired by the Senate majority leader, decides which provisions are “germane” to the budget and can be included in budget reconciliation.

To comply with the traditional Senate rules, Republican leaders crafted H.R. 1628 as a budget measure. Because of those rules, H.R. 1628 would eliminate or change many ACA taxes, such as the tanning salon tax. The bill also would change the current income-based premium tax credit subsidy to an age-based subsidy available to more people. The bill would not affect ACA provisions that clearly have no direct effect on federal spending, such as the essential health benefits package.

The EHB package is supposed to ensure that individual and small-group major medical coverage is solid coverage, and help consumers compare individual and small-group coverage on an apples-to-apples basis. The provision requires issuers, in most cases, to cover at least about 60 percent of the actuarial value of 10 types of care, such as hospital care and physician services. The U.S. Department of Health and Human Services has ruled that the EHB package must include coverage for mental health and substance abuse services.

Members of the Freedom Caucus, a House Republican group, have been pushing for a full ACA repeal bill, or, at least, a bill that would eliminate ACA provisions such as the EHB provision.

The EHB package requirement did not exist before 2010, but the idea of eliminating it has drawn harsh criticism. Margot Sanger-Katz, a New York Times reporter, quoted a health care management professor who said the change could produce a plan that would “cover aromatherapy but not chemotherapy.”

Some Republicans, including Sen. Ted Cruz, R-Texas, that Vice President Mike Pence has the authority to shape the budget reconciliation process, and that Republicans should be able to use that authority to get a full ACA repeal-and-replace bill through the Senate with 51 votes.

But another problem is that an ACA bill that appeals to Freedom Caucus might not be able to win support from Senate Republicans such as Susan Collins of Maine and Dean Heller of Nevada.

A bill that’s too liberal to appeal to the Freedom Caucus might lose the votes of some Senate Republicans, such as Cruz and Rand Paul.

In theory, more moderate Republicans and Democrats, such as Collins, Heller and Sen. Chuck Schumer, D-N.Y., could team up to come up with a bipartisan ACA change bill.

Rep. Jared Polis, D-Colo., said he’s still hoping for a bipartisan ACA change effort Wednesday, during the House Rules meeting. He said and many colleagues had been eager to push for ACA changes for years and would like to work with Republicans on a bill.

One challenge is that health insurers are preparing filings for the 2018 market now and need to know what the rules will be last month.

Another challenge is that the calendar affects budget measures and ordinary bills differently, according to James Slotnick, a government relations executive at Wellesley Hills, Massachusetts-based U.S. arm of Sun Life Financial Inc.

Lawmakers could introduce a bipartisan ACA change bill at any time during the session.

If, however, Republican lawmakers want to use one budget measure for changing the ACA, and one for tax reform, then they must complete work on the ACA-changing measure by April 28, before the end of the 2016 budget window, Slotnick writes in an analysis of the process.

“Once the 2017 budget window opens, Republicans will try to use budget reconciliation to move individual tax reform though the Senate,” Slotnick writes.  

Related:

CBO sees AHCA cutting $337 billion from the deficit

Ryan clings to core of GOP health bill as opposition mounts

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