WASHINGTON -- Sweetening the pot to win over fence-sitters in the GOP, House Republicans issued a letter Monday night suggesting changes to the American Health Care Act (AHCA), as the Affordable Care Act "repeal and replace" bill is known.
Many of the changes in target the Medicaid program. But other suggestions in the amendment letter would hasten the repeal of the majority of the taxes already slated for repeal in the bill, by one year, from the end of 2018 to 2017 — including the medical device tax, the tax on presciption drugs, the Medicare tax surcharge, the tanning salon tax and the net investment income tax. And the amendment letter delays the "Cadillac tax" on high cost plans an additional year, from 2025 to 2026.
The changes found a champion in insurers and not softening resistance from one of the nation's largest physician organizations, the American College of Physicians.
America's Health Insurance Plans issued a press statement, lauding provision that would help establish a "strong stable individual market" that could offer patients more options and lower costs.
Nitin Damle, MD, MS, president of the American College of Physicians said the nation's internists remained extraordinarily concerned. The ACP expressed the group's continued disappointment with the replacement bill including its amendments, in a
Notably, the leadership's Monday night fix letter suggested shortening the deadline for states that want to expand Medicaid from 2019 to 2017. Other changes:
- Limits the enhanced match for Medicaid expansion states to cover “able-bodied adults†as of March 1, 2017.
- Permit states that wish to continue to cover Medicaid expansion enrollees after than cut-off to do so at the initial federal medical assistance percentage (FMAP) instead of the enhanced matching rate.
- Permit states to establish a work requirement for non-disabled, non-elderly non-pregnant adults that must be met before they can receive Medicaid coverage. (States that opt for a work requirement would be granted additional dollars.)
- Give states the option to finance Medicaid through a block grant -- a lump sum payment -- rather than a per capita allotment.
"All of this makes [the AHCA] look less like Obamacare lite and more of a reform bill because they are getting rid of it quickly" said Douglas Holtz-Eakin, president of the American Action Forum who served as director of the Congressional Budget Office from 2003- 2005, in a phone call, referencing the expansion and the taxes.
To House conservatives, the Medicaid expansion was seen as "the heart of Obamacare" so limiting that expansion is hugely important, Holtz-Eakin added.
He clarified that while the bill limits the ability of states to allow new Medicaid expansion, "it doesn't roll anything back immediately." Existing enrollees who are "grandfathered" would however get the enhanced match for a period.
Regarding the option to allow states to choose between a block grant and a per-capita cap, Timothy Jost, JD, emeritus professor at Washington and Lee University, said either one would shift more cost onto states.
Jost said he doesn't know where more Medicaid efficiency is expected to come from -- Medicaid is already the bargain basement payer.
"I don't see Medicaid as a problem that needs to be solved, I think of Medicaid as a success story," he said.
The issue with Medicaid is not that the program is running out of money, "the problem is how to allocate [money]," Jost added. He said the most "striking" aspect of the AHCA is that it gives $900 billion to wealthy families, pharmaceutical companies and insurers, and the manager's amendment moves up those "tax giveaways" allowing them to be implemented a year sooner.
"It feels like this is a lot more restrictive," said Kavita Patel, MD, a non-resident fellow at the Brookings Institution and a primary care internist at Johns Hopkins Medicine, referring to the proposed changes to Medicaid.
"These are not fundamental changes." said Joseph Antos, PhD, of the American Enterprise Institute, who described the revision as "fine tuning" of the bill.
He was puzzled by the reported additional $85 billion over 10 years to help older adults afford healthcare.
Rather than implement the change in the House bill, the letter makes a suggestion to the Senate.
"It's a little hard to see how that kind of provision really buys votes," he said, noting that conservatives would want to see less funding in the bill not more.
Of the new funding for older adults, Patel said, "It's adding money to a very flawed structure."
This is a problem, because the more expensive care becomes for older people, the less likely they are to get it, Patel said.
"Those are the populations that you actually want to bring into the healthcare system," she added.
The real question right now looks at the big picture: Will the bill pass?
"I've always thought this was going to be really tight. I still think it's going to be really tight," said Holtz- Eakin.
Jost believes the bill will probably pass. "I think it will be a huge embarrassment to President Trump if it doesn't."
Patel agreed adding that the Senate is less of a certain bet.
"The senate is the real mystery," Antos said. Republicans in the Senate can only lose two votes and right now he said it's easy to find more than 4 who would block it.
One of those key votes, Sen. Tom Cotton (R-Ark) said in a on Tuesday, "The amendments improve the Medicaid reforms in the original bill, but do little to address the core problem of Obamacare: rising premiums and deductibles, which are making insurance unaffordable for too many Arkansans."
Cotton said he does not expect the bill to pass.