This afternoon, the U.S. House of Representatives passed an amended version of the American Health Care Act (AHCA) by a vote of 217-213, with all Democrats and 20 Republicans voting no. Along with the original bill’s repeal of Medicaid expansion and insurance mandates, and capping of federal Medicaid payment, the amendments create the option for states to opt out of key requirements of the Affordable Care Act (ACA) and provide $8 billion to fund state high-risk pools or other support for those who cannot afford health insurance.

The previous version of the bill, which failed to come to a vote in March, was criticized from various perspectives. Some lawmakers were concerned that the bill retained too much of the Affordable Care Act, and others were concerned that it removed protections from vulnerable citizens and would increase the number of people without health insurance. The Congressional Budget Office (CBO) analysis of the bill found that it would have increased the number of uninsured by 24 million. The amended bill has not been scored by the CBO.

Below are key elements of the original bill that remain intact and amendments to the bill. This list is drawn from Kaufman’s Hall previous reporting on the AHCA and on research by The Commonwealth Fund, The Kaiser Family Foundation, and health law expert Tim Jost, Emeritus Professor at the Washington and Lee University School of Law, on the amended bill’s waivers and additional funding conditions.

Key Elements Retained from the Original AHCA

  • Ending Medicaid expansion in 2020
  • Changing Federal Medicaid payments from cost-based to per capita, effectively capping payments
  • Repealing the individual mandate to obtain health insurance and the employer mandate to provide health insurance
  • Placing a surcharge on individuals who have a gap in insurance coverage
  • Changing the basis of subsidies to purchase insurance from income to, primarily, age
  • Allowing insurers to charge higher premiums to older Americans
  • Eliminating taxes that have been used to fund the ACA

Key Amendments

  • Allowing states to apply for waivers to certain ACA provisions that would let insurers:
    • Charge more to people with pre-existing conditions (as long as the state has a program to assist those people)
    • Modify the essential benefits package required under the ACA
  • Providing an additional $8 billion between 2018 and 2023 to states that have received a waiver to assist individuals who are subject to a premium increase because of the waiver; the form of this assistance—for example, high-risk pools or direct subsidies—is not specified

Implications

The amendments to the bill appear designed to answer concerns about its similarity to the ACA by creating the option for states to opt out of key provisions, as well as concerns about effects on those who may not be able to afford insurance by providing additional federal assistance funding.

In the absence of a score by the CBO, there is no government-sanctioned measurement of how this bill would affect the number of uninsured or underinsured, or the amount of federal healthcare spending. However, industry analysts say that the amended bill still would increase the number of uninsured Americans and that the additional $8 billion in funding is not enough to support those with pre-existing conditions who would not be able to afford coverage. Industry trade groups have expressed their concerns about and opposition to the amended bill.

For providers, the implications if this bill were to become law remain the same as those we listed pertaining to the original version of the AHCA:

  • Lower subsidies to purchase insurance for those in need
  • Potential loss of insurance for those covered under Medicaid expansion
  • Potential reduction in benefits and payment

This could mean that providers find themselves treating a population that is sicker while facing an increase in uncompensated care and bad debt, and reduced Medicaid payments.

What’s Next

The bill’s chances for a favorable vote in the Senate are hard to predict, where Republicans can afford to lose only two votes. However, the Senate likely will revamp the House version significantly, making vote counting difficult at this stage. The Senate vote is expected to take place in June or July.

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