Revised AHCA Bill Wins House Support, Moves on to Senate

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House Republicans have passed a revised version of the American Health Care Act (AHCA) by a vote of 217 to 213, without any Democratic support, and despite strenuous opposition from the healthcare community.

The passage followed months of debate and a failed first attempt at House approval on March 24. The bill, which is expected to deprive millions of Americans of insurance coverage, now goes to the Senate where it is expected to face a more difficult test, as the Republicans there hold a slimmer majority.

Crafted as a replacement for the Affordable Care Act (ACA), the AHCA bill includes a last-minute provision for $8 billion in additional funding to ensure coverage of pre-existing health conditions. That provision helped garner support from Republican House members who felt the bill would not provide enough coverage.

Republicans had contended that the ACA was expensive and structurally untenable in the short and long term, and was suffering from flagging support from the payer community. In debate leading up to the vote, Paul Ryan, speaker of the House, said the ACA “means even higher premiums, even fewer choices, even more insurance companies pulling out, even more uncertainty and even more chaos.”

Democrats continued their scathing criticism of the bill, reiterating everything they had objected to in March while claiming the state waiver on pre-existing conditions had “made a bad bill even worse.” Critics accused Republicans of trying to rush the measure through before the Congressional Budget Office (CBO) could update its appraisal of the bill. The CBO had estimated that 24 million people would be uninsured by 2026 under the previous version of the AHCA.

That iteration of the bill was pulled from consideration entirely when GOP leaders realized the bill did not have the support to pass the House. The most striking difference between the two versions is the Meadows-MacArthur amendment, which allows states to eliminate the ACA’s pre-existing condition protections. The Meadows-MacArthur amendment helped win over the right-wing Freedom Caucus, which led the charge to sink the previous version of the AHCA.

Concessions were made to the party’s center as well. Rep Frank Upton (R, Michigan) flipped to favor the bill after funding for the high-risk pools was included. Upton had been previously critical of the impact the AHCA may have on those individuals.

The revised AHCA would undo many of the signature provisions of the ACA, such as the tax on Americans who don’t purchase health insurance and the so-called “Cadillac tax” on high-end health plans. Also, states would not have to require payers to cover “essential health benefits,” nor would payers have to charge the same price to everyone regardless of their health history.

Consumer and industry groups immediately panned the vote.

“Allowing patients to be charged more for coverage based on their health status risks making pre-existing condition protections virtually meaningless,” the Cancer Action Network of the American Cancer Society wrote. “A return to medical underwriting, combined with seriously weakened standards for what constitutes good coverage through the erosion of essential health benefits, sets up a situation whereby payers can cherry-pick their customers and leave patients with serious conditions like cancer with few if any affordable insurance options,” it said.

ASH President Kenneth C. Anderson, MD, also issued a statement criticizing the bill. “Since the early days of health care reform, ASH has remained committed to supporting access to affordable, high-quality health care for all Americans,” he wrote. “We are deeply disappointed that the U.S. House of Representatives today passed a bill that would price the oldest and sickest Americans out of affordable health insurance coverage by waiving requirements for community rating and age rating, scaling back funding for Medicaid—a vital lifeline for many with blood diseases like sickle cell disease and hemophilia—and permitting states to opt out of requiring coverage for essential health benefits.”

The AHCA would also phase out the Medicare expansion that provided coverage for adults making up to 133% of the federal poverty line. In addition, the bill would provide for up to $883 billion in tax reductions, reversing the shift of wealth from rich to poor that has been a hallmark of the ACA.

ASCO had previously issued a vigorous condemnation of the AHCA bill and urged the House to vote it down, writing that that the AHCA would reduce meaningful access to high-quality care by adding provisions that would increase costs, decrease access to appropriate treatment, and widen existing disparities in cancer care.

Following the vote, ASCO President Daniel F. Hayes, MD, issued the following statement: “We remain concerned that the AHCA may not include adequate pre-existing condition safeguards, and therefore does not meet ASCO’s guiding principles for healthcare reform, which call for preserving the current ban on pre-existing condition limitations. This key patient protection clearly remains jeopardized, even under the last-minute negotiated agreement to provide $8 billion over five years for high-risk pools. Doubtful that this funding level comes close to covering all individuals with pre-existing conditions, many experts agree that high-risk pools still deprive the most-ill patients of critical medical care. Even the sponsors of the compromise measure have expressed uncertainty about the adequacy of this funding level. We now call on the Senate to work with us toward real healthcare reform that will improve cancer care for all Americans.”

Many experts doubt that this money will come close to covering all individuals with pre-existing conditions, and agree that high-risk pools still deprive the most-ill patients of critical medical care. Even the sponsors of the compromise measure have expressed uncertainty about the adequacy of this funding level. We now call on the Senate to work with us toward real healthcare reform that will improve cancer care for all Americans.”