House leaders completed one major round of work on changing the Affordable Care Act on Thursday, when they pushed H.R. 1628, the American Health Care Act, through on a 217-213 vote.
Now Senate Majority Leader Mitch McConnell is the showrunner for the new version of the ACA change show, with Susan Collins of Maine, Dean Heller of Nevada and Lamar Alexander of Tennessee playing leading roles in coming up with a change measure that can actually get through the Senate and then the House.
Senators could simply pass H.R. 1628 as is, tweak the measure and pass it, or come up with their own alternative. In January, for example, Collins and Sen. Bill Cassidy, R-La., released their own ACA change proposal.
Bloomberg is reporting that Alexander, chairman of the Senate Health, Education, Labor and Pensions Committee, has already announced plans to develop a new bill.
The negotiations are so tricky because Republicans have only a modest majority in the House and hold just 52 of the 100 seats in the Senate.
President Donald Trump has shown little interest in following traditional government procedural rules. He might be able to make sweeping changes in how federal health laws, regulations and programs work on his own, by issuing executive orders and simply telling officials to change the way they do things.
For now, however, his administration appears to be trying to playing the game according to the traditional rules. That means the traditional rules could shape how the Senate version of the ACA change show looks for the next few weeks.
Here are ideas for agents, brokers and financial advisors about what might be coming next:
1. Budget reconciliation measures are unlikely to actually repeal the ACA.
Under traditional Senate rules, an ordinary bill needs support from 60 senators to reach the floor without facing the threat of a filibuster, or endless round of debate.
A budget bill needs just 51 votes. Vice President Mike Pence, a Republican who is almost certain to vote for any Affordable Care Act change bill that Republican Senate leaders support, could cast a vote to break a tie.
To qualify for special budget measure treatment, a budget measure must not do much to increase the federal budget deficit. The provisions in the measure must be “germane to the budget.”
Opponents of the ACA do not believe that they could get a true ACA repeal bill classified as a budget measure, because many ACA provisions, such as the ACA essential health benefits package provision and the ACA summary of benefits and coverage notice requirement, have little to do with federal spending or efforts to raise federal revenue.
One effect of this is that H.R. 1628 and the most commonly discussed Senate ACA change proposals are not actually ACA repeal bills. They would not repeal the laws in the ACA package, the Patient Protection and Affordable Care Act of 2010 and the health care provisions in the Health Care and Education Reconciliation Act of 2010.
H.R. 1628 would not eliminate the ACA public exchange system or the SBC notice requirement, and it would not directly affect the existence of the essential health benefits package.
The SBC program is the one that makes insurers and health plans provide standardized “milk carton labels” for health plans.
The EHB package is supposed to require all individual and small-group insurance policies to cover what Congress classified as 10 key types of care, including hospital care, physician care, and care to help people born with disabilities maximize what they can do.
That means any Republican senators who are ambivalent about attacking the ACA may be able to justify voting against a Senate ACA change bill by declaring that the bill is a sham, because the bill does not actually repeal the ACA.
2. Impact analysis of risk pool proposals could get hairy.
Before the Affordable Care Act came along, uninsured people with serious health problems in many states had no practical way to get covered.