By Sara Wilensky, JD, PhD
Co-author of Essentials of Health Policy and Law, 3rd Edition
After a flurry of behind-the-scenes arm-twisting by President Trump and negotiations with members of their own party, the Republican leadership tabled the American Health Care Act (AHCA) on March 24th because they did not have the votes to pass the bill. Instead of being a bill that had a little bit for everyone, AHCA ended up as a bill that did not have enough for anyone. It was too moderate for conservatives, too conservative for moderates, and managed to alienate powerful stakeholders ranging from conservative think tanks to providers to the elderly. So, what did we learn and what happens next?
First, Republicans will not be able to win votes only by relying on party loyalty or helping Trump be a successful president. Speaker Ryan and President Trump appeared to bank on his members feeling so compelled to pass something to repeal the Affordable Care Act (ACA) that they would pass anything even if they did not like the bill. In the end, policy mattered. Whether it was ideological opposition to refundable tax credits by conservatives or concern about millions losing health insurance by the moderates, the details of bill were important to members. This is not surprising given the unpopularity of the bill. A majority of those polled opposed major components of the Republican plan such as including allowing insurers to charge older individuals higher premiums (80% opposed), adding surcharges for lapsed coverage (70% opposed), reducing Medicaid funding (64% opposed), and denying funding to Planned Parenthood (56% opposed). More respondents opposed eliminating the individual mandate than keeping it (48% to 35%) and replacing income-based subsidies with age-based subsidies (48% to 16%). Overall, 56% of the public opposed the AHCA and only 17% favored the bill.
Second, while passing a bill is easier when your party controls Congress and the White House, the “physics” of politics still remain. The Republican leadership tried to do in weeks what usually takes months. They wrote their bill quickly and in relative seclusion instead of taking the time to brief their members, sell them the bill, and incorporate their ideas. They also did not reach out to the general public or key stakeholders, who ended up opposing the bill.
Third, it is always harder to take benefits away then to grant them in the first place. A poll taken the week of the scheduled vote on AHCA found that 65% of registered voters wanted the ACA kept the same or strengthened, a 7% increase from the month before. Even Republicans soured a bit on repealing the ACA, with the poll showing 57% favoring repeal, an 11% drop from the prior month.
The aftermath of the Republican’s failed effort has been a constantly moving target of laying blame and making plans. President Trump first blamed the Democrats for not voting for the bill and predicted they would come to him to make a deal once the ACA collapsed on its own. He soon pivoted to blaming the conservative Republican Freedom Caucus for not being willing to make a deal to pass the AHCA and indicated a willingness to work the Democrats on a new path forward. Just recently, however, Speaker Ryan made the remarkable statement that he was not interested in working with Democrats on health reform and would continue forging ahead with a “Plan B” that could be approved by the Republican party. In the Senate, however, a number of Republican Senators commented that there might be a bipartisan path forward and Sen. Corker (R-TN) explicitly denounced Ryan’s comments.5 In other words, it is quite unclear at this point whether those who favor a bipartisan approach will win out over those who do not. It would be surprising, however, if the Republicans could pass a bill in the House with only Republican support that would also survive a Senate vote, for all of the political reasons discussed in earlier posts.
So what happens now? A new ACA-replacement bill appears to be long way off, if it ever occurs. Given the bruising loss, difficult politics, and other major priorities (tax reform, infrastructure, etc.), it is hard to see Congress spending a lot of time on health reform in the near future. The administration, however, has many tools at its disposal (e.g., signing Executive Orders, re-writing regulations, approving waivers) and it will be interesting to see how they employ them. If the administration decides it would like to facilitate the demise of the ACA, it can take steps big and small to do so.
The administration has already taken some actions to alter the ACA. On his first day in office, Trump signed an Executive Order that allowed HHS and other agencies to “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the [ACA] that would impose a fiscal burden” on the states, individuals, or other entities involved in health care. While the changes that could take place under this Executive Order are unclear, the intent to free individuals and states from ACA obligations is unmistakable.
The administration also proposed a rule to make it more difficult to sign up for insurance during a special enrollment period, shortened the length of the next open enrollment period, and make it easier for insurers to collect back premiums., In addition, the administration weakened enforcement of the individual mandate by ordering the IRS to continue processing tax returns even if filers do not indicate whether they had insurance coverage.7 Examples of other actions the administration could take include withdrawing the appeal of a case that could eliminate cost-sharing subsidies, granting more hardship waivers to exempt people from complying with the individual mandate, limiting advertising during the next open enrollment period, granting Medicaid waivers to the states to allow work-requirements or increased cost-sharing, re-writing regulations to allow for skimpier benefits under the essential health benefits requirement, eliminating contraceptives from the list of women’s preventive services, or eliminating women’s preventive services altogether.,,
Of course, Trump could decide that it is not in his best interest to let the ACA implode and there is no shortage of suggestions about ways to improve the ACA. Republicans control Congress and the White House so voters may blame them if their health insurance situation worsens, even if the ACA was a law originally passed by the Democrats. Since Trump does not appear to be wedded to a specific policy proposal, he may decide that working with the Democrats to stabilize and improve the ACA is his best political move.
Sara Wilensky is Special Services Faculty for Undergraduate Education in the Department of Health Policy and Management at the Milken Institute School of Public Health at the George Washington University. She is also the Director of the Undergraduate Program in Public Health. As both a teacher and a researcher, Dr. Wilensky concentrates on the financing, access and health care needs of the medically underserved, including low-income and uninsured individuals, farmworkers and patients with HIV and AIDS. She is the co-author of Essentials of Health Policy and Law from the Jones & Bartlett Learning Essential Public Health series.
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