Late last night, after scuttling a planned vote on a bill to repeal the Affordable Care Act, Republicans huddled behind closed doors in the basement of the Capitol to attempt to hash out their difference. What resulted was the release of a new amendment to the bill and the ultimatum that Republicans must vote for the legislation Friday or suffer the political consequences.
Passage is far from certain, as conservative and moderate Republicans alike express deep misgivings about the original bill and its last-minute changes—which will allow states gut the rule that insurance companies cover 10 Essential Health benefits, delays a Medicare tax on the wealthy for five years, and allocates an additional $15 billion for states to help cover maternity, mental health, and substance abuse costs.
The House plans to pass the bill after just four hours of debate on Friday, having already waived a rule that they take at least an entire day to read a revised bill before holding a vote. Though the Congressional Budget Office released an updated score of the bill on Thursday that took into account previous amendments—and found they would achieve $186 less in deficit reduction while still leaving 24 million people without health insurance—there is no way lawmakers will see an analysis of the final legislation by the time they vote.
Here are the changes released late Thursday night:
1. The amendment would roll back the Affordable Care Act’s Essential Health Benefits mandates. This one is the biggie, and it was what conservatives were pushing for before President Trump put an end to negotiations. It tampers with the law’s requirement that insurers offer plans that include 10 broad coverage areas and turns the responsibility over to the states to establish their own essential health benefits standards for the purposes of what plans are eligible for the GOP bill’s tax credits.
However, as health care experts like University of Michigan Law School professor Nicholas Bagley and Washington and Lee health law specialist Timothy Jost have pointed out, the text appears riddled with errors and hasty policy-making. For one, it sets this transition for 2018, meaning states would have only a few months to establish their own essential health benefits before insurers must submit their plans. The amendment also appears to create for Republicans their own King v. Burwell problem, in that, if read plainly, consumers could only use tax credits on plans that adhere to states’ essential health benefits standards, leaving no back-up for consumers if states fail establish their own standards.
“If [the amendment] becomes law, the individual insurance market will likely collapse nationwide in 2018,” Bagley said.
2. The amendment throws more money, to the tune of $15 billion, at the legislation’s Patient and State Stability Fund for states to set up coverage for maternity, mental health, and substance abuse care. It is believed those areas of care, all mandated by the ACA, would be the first to go if the Essential Health Benefits were dismantled. Republicans were already beginning to see nasty headlines that they were stripping away the federal requirement for that care.
3. As the major pay-for for all these changes, the amendment delays the repeal of the so-called Medicare tax — a 0.9 percent tax on those making $200,000 or more individually — by six years, which would raise an additional $50 billion in revenue, according to Jost. Republicans will need this, not just for the $15 billion for maternity and mental health services but for the changes to Essential Health Benefits mandate. By removing those standards, it is believed that insurance will get a lot cheap because plans will be much more meager. The upshot is that more people will be able to afford it, even with Republicans’ paltry tax credits, and the government will be spending more on the tax credits than anticipated under the original legislation.