The Patient Protection and Affordable Care Act in the 115th Congress

The ACR is closely monitoring Congressional efforts to repeal and replace the Patient Protection and Affordable Care Act (PPACA).

Better Care Reconciliation Act of 2017

On June 22, Majority Leader Mitch McConnell (R-KY) released the first version of a comprehensive Senate Republican plan for repealing and replacing the Patient Protection and Affordable Care Act (PPACA), specifically the Better Care Reconciliation Act (ACR Summary of BCRA). Although similar in many areas, BCRA was a unique legislative proposal that was separate from the American Health Care Act, which passed the House of Representatives in early May 2017. Senate Republicans and outside stakeholders provided substantial feedback on the initial proposal prompting Senate Majority Leader McConnell to release a revised BCRA “discussion draft” on July 13. Read a detailed summary of Titles I and II of BCRA.

The American College of Radiology (ACR) closely monitored attempts by Senator Ted Cruz (R-TX) to add a new title Title III to the July 13 version of BCRA. In particular, the College monitored the impact of the Cruz amendment on subjecting patients to any cost sharing associated with receiving life-saving cancer screening services such as mammograms, low-dose CT screens for lung cancer, and CT Colonographies for Colon Cancer. Read a detailed summary of the newly added Title III of BCRA.

The politics surrounding BCRA remained so fluid that on July 17 Senate Majority Leader McConnell also released legislation, specifically the Obamacare Repeal and Reconciliation Act (ORRA) of 2017, which would simply eliminate the vast majority of PPACA effective in 2019. Unlike BCRA, the ORRA would not include any provisions to immediately replace the repealed portions of Obamacare with any Republican policy proposals. In addition to BCRA and ORRA, Senate Republicans also prepared what was colloquially referred to as a "skinny" Obamacare repeal bill, specifically the Health Care Freedom Act. The Health Care Freedom Act sought to, among other things, zero out penalties associated with the individual mandates, delay enforcement of the employer mandate through 2024, suspend the medical device tax through 2020, eliminate funding for Planned Parenthood for one year, and provide states with greater flexibility to pursue waivers from existing PPACA insurance regulations.

Ultimately, Senate Republicans were unable to corral the 51 votes needed to pass anylegislation to repeal and replace Obamacare under reconciliation, an arcane parliamentary procedure that prohibits a Senate filibuster and allows select bills to be passed with a simple majority. Majority Leader McConnell first aimed to pass the June 22nd BCRA discussion draft before the week long Independence Day District Work Period, however, the vote was delayed due to insufficient support for the bill.

On July 25, the Senate Republicans finally passed a “motion to proceed,” or an agreement for the Senate to begin debate on the Housed passed AHCA, by a bare 51-50 vote. In fact, Vice President Mike Pence was forced to cast the tie-breaking vote on the motion to proceed. In accordance with the rules governing reconciliation bills, the Senate immediately began 20 hours of debate and was expected to then move to a “vote-a-rama” on unlimited amendments to the AHCA so long as they met the aforementioned Byrd rules. The Senate, however, voted late on July 25th against the July 13 BCRA version that included Senator Cruz’s Title III provisions, as well as a late amendment proposed by Senator Rob Portman (R-OH). On July 26, the GOP pivoted to a vote on ORRA but this bill also failed by a wide margin.

Consideration of a “skinny” Obamacare repeal bill was designed to be a compromise to appease both conservative and moderate Republicans. Despite its unpopularity, Majority Leader McConnell pleaded with Senate Republicans to pass the Health Care Freedom Act in hopes of forging a conference committee with the House of Representatives. Republicans hoped final consensus around a more comprehensive package to repeal and replace Obamacare would be forged through a bicameral conference committee. Yet, in a dramatic vote cast in the early morning hours of July 28th, Senator John McCain (R-AZ) joined fellow Republican Senators Lisa Murkowski (R-AK) and Susan Collins (R-ME) in opposing the Health Care Freedom Act.

The failure of Health Care Freedom Act seems to have marked the end of this latest attempt to repeal and replace Obamacare. It is unclear whether Republicans and Democrats will begin working on a bipartisan solution to stabilize the individual market and improve other aspects of Obamacare. ACR’s Government Relations Office will continue to closely monitor the effort to repeal and replace PPACA.

American Health Care Act -- MacArthur-Meadows Amendment; Upton-Long Amendment

After numerous delays and back room negotiations, on May 4 the U.S. House of Representatives finally passed H.R. 1628, the American Health Care Act (AHCA), legislation that repeals major elements of the Patient Protection and Affordable Care Act (PPACA), commonly referred to as “Obamacare,” and implements numerous new conservative health care policies.

The measure was adopted by a vote of 217-213, with no House Democrats voting in favor of the legislation that will now be considered in the U.S. Senate under budget reconciliation, an arcane parliamentary procedure that prohibits a Senate filibuster and allows select bills to be passed with a simple majority vote.

A series of last minute amendments proposed by various House Republicans enabled the passage of H.R. 1628. The first amendment was negotiated primarily by Reps. Tom MacArthur (R-NJ), one of three co-chairs of the Tuesday Group, a 50-member bloc of moderate GOP House members, and Mark Meadows (R-NC), chair of the Freedom Caucus, a collection of approximately 30 ultra-conservatives. According to legislative text, the amendment would give states the option of waiving existing requirements pertaining to community rating and essential health benefits (EHBs) as long as certain conditions are met.

Please click here for a summary prepared by the ACR Government Relations Office of the MacArthur-Meadows amendment. Read a section-by-section analysis of the legislation.

Despite the addition of the MacArthur-Meadows amendment, numerous moderate Republicans, especially Representative Fred Upton (R-MI) and Billy Long (R-MO), continued to withhold their support for the legislation due to concerns that the changes to the bill still did not provide enough protection to individuals with pre-existing conditions. Both Reps. are prominent members of the Energy and Commerce Committee with Upton serving as the immediate past chair of the Committee.

According to the MacArthur-Meadows amendment, individuals who live in states that received a waiver and successfully established a high-risk pool, either through the federal government of the AHCA created “Patient and State Stability Fund,” may be charged higher premiums for pre-existing conditions. In addition, individuals subjected to higher premiums because of pre-existing conditions must show that they are seeking replacement health insurance following a 63-day or longer break in their previous coverage. Reps. Upton and Long felt that the MacArthur-Meadows amendment provided insufficient funding solely dedicated to helping individuals with pre-existing conditions that are placed in high-risk pools offset the cost of potentially rising premiums stemming from their health status. As a result, the two members of Congress negotiated directly with the Trump Administration on an amendment that would add an addition $8 billion over 5 years to the state high risk pools which presumably will be devoted to lowering premiums for beneficiaries with pre-existing conditions. Addition of this amendment finally placated enough moderates to enable the GOP House to pass the legislation.

House Republicans Cancel March Vote on AHCA

A lack of consensus among House Republicans forced Speaker Paul Ryan (R-WI) to indefinitely delay a March 24th vote on passage of H.R. 1628. This legislation would repeal major elements of PPACA, commonly referred to as “Obamacare,” and replaces them with new wide-reaching conservative health care policies.

The AHCA lacked the votes needed for passage. No House Democrats were expected to vote for H.R. 1628. A series of changes negotiated by President Donald Trump and House GOP leaders to placate moderate and hardline conservatives, most notably the House Freedom Caucus, failed to garner enough Republican votes.

House Republican leadership preferred to pass the bill in March so it could then be considered in the U.S. Senate under budget reconciliation, an arcane parliamentary procedure that prohibits a Senate filibuster and allows select bills to be passed with a simple majority vote. Prior to the cancellation of the vote, Speaker Ryan and Senate Majority Leader Mitch McConnell (R-KY) were committed to passing H.R. 1628 no later than April 7, 2017. In order to accommodate the Easter and Passover religious holidays, the House of Representatives held the April 2016 District Work Period between Monday, April 10th and Monday, April 24th.

As currently constructed, H.R. 1628 consists of five major policy components, specifically the elimination of many existing PPACA taxes, the creation of new health care tax credits to help individuals purchase health insurance, expanded access to health savings accounts (HSAs) and state innovation grants to help cover beneficiaries with pre-existing conditions and Medicaid reform.

The canceled vote comes on the heels of the U.S. House of Representatives releasing a managers' amendment to H.R. 1628 on March 20th. More specifically, the House Rules Committee released section-by-section analyses of the "Technical" and "Policy" changes to H.R. 1628, as well as the corresponding legislative text of the "Technical" and "Policy" sections of the Managers' amendment.

The release of the Managers' Amendment followed both the Ways and Means and Energy and Commerce Committees holding legislative "mark-ups," or the process of individuals serving on these particular committees reviewing bills and formally proposing potential amendments, related to H.R. 1628 on March 8th. The House Ways and Means and Energy and Commerce Committees separately released legislative language dealing with policy concepts that pertain to their specific legislative jurisdiction. In addition to formal bill language, both committees prepared section-by-section summaries of the legislation. Please find the initial Ways and Means section-by-section summary here, while the initial Energy and Commerce section-by-section summary can be found here.

Repealing PPACA

On January 3, 2017, federal elected officials serving in the 115th session of the United States Congress were officially sworn in as members of Congress. Following the election of Donald Trump as President of the United States, Republican majorities in the House of Representatives and Senate identified passage of legislation to repeal and replace the Patient Protection and Affordable Care Act (PPACA) as its primary goal. The ACR’s Government Relations Office is closely monitoring the effort to both repeal and replace PPACA and this section of the web page is designed to serve as an information “clearing house” for the latest developments surrounding the current health care reform law.

Budget Reconciliation

The GOP is expected to utilize a parliamentary maneuver entitled “budget reconciliation (Senate Budget Reconciliation Background and Committee for a Responsible Budget Reconciliation) to accomplish the massive goal of repealing the current health care reform law. Budget reconciliation is a Congressional procedure allowing for expedited consideration of certain tax, spending, and debt limit legislation. Since Senate Republicans do not have a filibuster proof majority, the key Senate procedural benefits of utilizing reconciliation are as follows: 1) reconciliation bills cannot be filibustered; 2) floor debate is limited to 20 hours 3) there is no limit on the total number of amendments that can be proposed, however, only germane amendments that affect spending (ultimately determined by the Senate parliamentarian) can be considered; and 4) final passage only requires a simple majority. Before reconciliation can even be deployed, the House and Senate must first pass a federal budget.

Below is a tentative outline and timeline for how Congressional Republicans would like to proceed with the overarching effort to repeal and replace PPACA via budget reconciliation:

  1. The Senate is expected to vote first on its formal budget resolution (2017 Senate Budget Resolution) for the 2017 Fiscal Year in early January. The vote on the budget resolution, which is tentatively scheduled for the week of January 9th, does not make any actual changes to the health care reform law at that time. The budget resolution only includes instructions for select House and Senate Congressional committees to identify specific PPACA sections to be repealed.
  2. The House then votes on the Senate passed budget resolution. Again, the House passage of the Senate budget resolution does not make any actual changes to PPACA.
  3. After the House and Senate pass a budget resolution, the process of identifying sections of PPACA to repeal can move forward, starting in the House since it’s a revenue bill. The House committees with jurisdiction over health care, specifically the Committees on Energy and Commerce and Ways and Means, will each identify aspects of PPACA to repeal. The policy recommendations from the key House health care committees will then go to the House Budget Committee which, in turn, compiles these various concepts into a single reconciliation bill to repeal key aspects of PPACA.
  4. The reconciliation PPACA repeal bill will then go to the House floor for a vote.At this point, expect the legislation to resemble the reconciliation bill Republicans passed and former President Barack Obama vetoed in 2015.That particular bill struck down PPACA’s Medicaid expansion, premium tax credits, cost-sharing reduction payments and other provisions, while eliminating the penalties tied to the individual and employer mandate.
  5. Assuming House passage, the reconciliation PPACA repeal bill will then go to the Senate floor. It’s unclear at this time whether the House passed reconciliation PPACA repeal bill will be sent to the Senate committees with direct jurisdiction over health care, specifically the Committees on Finance and Health, Education, Labor, and Pensions (HELP), for consideration and potential amendments. Regardless, the House passed PPACA reconciliation bill will be subject to another lengthy Senate debate. Senate Republicans will likely try to get additional pieces of the health law added to the reconciliation bill. Democrats will likely push back and force floor votes on key amendments. Eventually, the full Senate will vote on the final reconciliation PPACA repeal bill and it is expected to pass with a simple majority, likely along party lines.
  6. Lawmakers deal with any differences between the two bills. If the Senate version of the reconciliation PPACA repeal bill has changed since it passed the House, the changes will need to be rectified either via a House-Senate conference committee OR a House vote on the Senate-approved bill. Ironing out any potential differences between the two bills is expected to occur quickly.
  7. Final bill is sent to the White House to be signed by President Trump into law. Once signed into law, the elements of PPACA identified and passed via reconciliation are officially repealed.  

Please note that the PPACA repeal timeline is subject to change due to a number of factors, including alternative preferred changes or internal disagreement amongst Congressional Republicans, opposition from Congressional Democrats, or objections from the Trump Administration.

Early Detection Cancer Screening Services

Throughout the entire effort to repeal and replace PPACA, ACR’s Government Relations Office will work diligently to protect patient access to life-saving cancer screening services administered via diagnostic imaging, including mammograms, low-dose CT (LDCT) lung cancer screens, and CT Colonographies (CTC). ACR is pleased to work with Congressional Republicans and Democrats to ensure that all Americans retain the health care and fiscal benefits associated with access to annual early detection cancer screens.