The GOP replacement bill is out. Now what?

  | June 21, 2017

Updated on June 23

As the healthcare industry scrambled to digest CMS's proposed new rule on MACRA, the Senate provided a bigger distraction: A draft of its version of a bill to repeal and replace the Affordable Care Act. Senate Republicans are aiming for a vote before members of Congress leave town for the July 4 recess.

As that deadline draws nearer, activity on Capitol Hill is heating up. Here is the latest news and what to watch for.

Details of the Senate plan revealed

In broad strokes, the Senate's version of the bill is significantly similar to the House bill. But there are some small but potentially meaningful changes around how Medicaid expansion is rolled back, the funding of traditional Medicaid, and how much individuals can be charged for and helped to pay for insurance. Several members have expressed concern and want changes to the current language, so don't be surprised if a vote does not happen next week and negotiations spill into July. 

Democrats fight the Senate bill 

Senate Democrats are unsurprisingly critical of the newly released bill language. Expect them to continue pulling all of the procedural levers at their disposal to disrupt the GOP bill’s path to a vote.

Trump sends mixed signals 

In his meeting with Senate Republicans last week, the President urged lawmakers to pass a "generous" bill, apparently calling the House version "mean" and difficult to defend (though he celebrated that same bill in the Rose Garden in May and has called it “terrific"). But he also reminded his audience of the need to make good on the GOP's seven-year campaign to repeal the ACA.

Through tweets Thursday night and Friday morning on Fox and Friends, Trump signaled his support for the Senate bill. The President remains confident that Congressional leaders can negotiate a final package that fixes a complicated problem and addresses the concerns of the moderate and conservative wings of his party.

Democrats ask if HHS is breaking the law by promoting repeal and replace 

In a letter to U.S. Comptroller General Gene Dodarao, the ranking members of four committees asked if HHS's recent social media activities calling for repeal and replace of the ACA violate the Consolidated Appropriations Act and the Anti-Lobbying Act. Those laws prohibit use of federally appropriated funds to support the enactment of legislation pending before Congress.

House approves three "replace" bills 

The bills, part of the larger Republican replacement strategy, are quite narrow compared to the repeal bill passed earlier this year — and presuppose that the American Health Care Act will soon be the new reality. They would allow veterans to access tax credits under the AHCA if not already enrolled through the VA, allow AHCA tax credits to be used toward COBRA coverage, and require verification of citizenship before tax credits can be accessed.

Nevada Governor vetoes a Medicaid 'public option' bill

Republican Governor Brian Sandoval last week vetoed legislation that would have allowed individuals to buy into Medicaid. This was the public option that Democrats have supported since the early debates on the ACA. Sandoval said that the measure, approved in the Democrat-controlled legislature, needed to be studied more, cautioning that moving too quickly would risk rocking an already fragile healthcare market.

Turmoil for the 2018 insurance marketplaces continues 

Also in Nevada, Aetna announced last week that it may sell exchange plans in Nevada after all. Previously, the insurer had declared that it was completely abandoning the exchange markets. Aetna's new announcement implied that it may have to sell insurance in Nevada based on contractual obligations in the state.

Meanwhile, Anthem announced that it is pulling out of Ohio, leaving many counties in that state without any exchange plan options. 

Missouri and Tennessee have similar situations. Insurance start-up Oscar Health announced that it is partnering with Cleveland Clinic to offer individual plans in Ohio next year, but those plans likely will not cover all of the counties left bare by the Anthem decision.

Iowa is also facing a potential coverage gap in 2018, and has proposed a waiver plan that, if approved by the Trump administration, would establish a new health plan with standardized benefits, a reinsurance program to offset costs from expensive patients, and premium subsidies.

Cost-sharing questions remain

Intertwined with this turmoil is the open question of what the Trump administration is going to do about cost-sharing subsidy payments for insurers on the exchanges. Administration officials announced that they would make the cost-sharing subsidy payments to insurers for June, but once again declined to offer any commitment beyond this month. And by August, the administration must decide whether it will defend the legality of the subsidies at all, in a court case it inherited from the Obama administration.

The Senate repeal bill in its current form will, in theory, address this concern by funding the subsidies for several years. Yet it also allows the Trump administration to stop the subsidies earlier, so the uncertainty may continue.

Insurers had to decide on Wednesday whether to file plans for 2018 exchanges. The upheaval in Washington played a role in those decisions — you can be certain of that.

Stephanie Zaremba is director of government affairs at athenahealth.

The GOP replacement bill is out. Now what?