February 17, 2017

House Conservatives Take Hard Line on PPACA Repeal

The House Freedom Caucus and select members of the Republican Study Committee announced Feb. 14 that they will begin pushing Speaker Paul Ryan (R-WI) to immediately pass legislation to repeal the Patient Protection and Affordable Care Act (PPACA), irrespective of whether the GOP’s alternative health care reform policy proposal is finalized.

The pressure from arch conservatives in the House comes in response to the perception that the GOP leadership is wasting too much time and political capital debating key components of the Republican health care reform alternative.

Speaker Ryan and moderate Republicans, however, are committed to using reconciliation, a parliamentary maneuver that enables bills to receive expedited consideration in both the House and Senate, to repeal key components of PPACA and enact major policy pillars of an alternative to Obamacare. Sen. Lamar Alexander (R-TN), chair of the Health, Education, Labor and Pensions (HELP) Committee, is the leading proponent of a deliberate approach to health care reform. He also favors using reconciliation to repeal and replace PPACA.

Unlike traditional legislation, bills considered under reconciliation can pass by simple majorities and are not subject to a Senate filibuster. To ensure its limited use, however, amendments considered under reconciliation rules must be deemed germane to the underlying budget proposal and are not permitted to increase the federal deficit. In the Senate, the parliamentarian reviews the bill and employs arcane “Byrd Rules,” named after the late Sen. Robert Byrd (D-WV), to deem whether each provision meets the high threshold for being considered under reconciliation.

Under Ryan’s preferred strategy, House and Senate Republicans would develop legislation that closely resembles H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act, which passed both houses of Congress in 2015 but was ultimately vetoed by former President Barack Obama. H.R. 3762 repealed the individual and employer mandate, the health insurance premium tax credits and cost-sharing subsidies, the small business tax credit, the Medicaid expansion policy, as well as a whole host of imbedded taxes and fees, such as the medical device tax and “Cadillac” tax on generous health insurance plans. Full repeal of the Medicaid expansion has also divided the Republican caucuses in the House and Senate because many GOP governors utilized this policy to expand health care coverage in their states.

Ryan, however, is also signaling his desire to use the reconciliation bill to enact the key pillars of the Republican plan to replace PPACA. Although its specific details have not been officially released, it is widely expected that the GOP’s health care alternative will focus on expanded access to health savings accounts (HSAs), state-run high-risk pools for patients who have pre-existing conditions and universal tax credits to enable individuals to purchase health insurance. Gaining consensus on the primary aspects of an Obamacare replacement bill, however, has proven difficult for Republicans, and it has delayed the introduction or passage of any legislation under reconciliation.

Rather than debate and finalize the intricacies of a replacement bill, the House Freedom Caucus wants Speaker Ryan to quickly reintroduce and pass legislation solely focused on repealing key aspects of PPACA. These staunch conservatives believe action on PPACA repeal needs to take place immediately and, at the very least, should eliminate all of the same policies included in H.R. 3762. With 50 pledged members, the House Freedom Caucus is a sizable coalition of Republican members who could easily derail any reconciliation effort in the House. Although eager to placate the more conservative wing of his party, Speaker Ryan also has to balance concerns about crafting a bill that is too aggressive for the Senate where Republicans only have a four-seat majority.

The American College of Radiology will continue to monitor all the ongoing developments related to the effort to repeal and replace the PPACA. Members should continue to follow the Advocacy in Action eNews for the latest information.