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$8 Billion Deal Gives Crucial Momentum to G.O.P. Health Bill $8 Billion Deal Gives Crucial Momentum to G.O.P. Health Bill
(about 5 hours later)
WASHINGTON — Two Republican lawmakers who had come out against the House bill to repeal the Affordable Care Act earlier this week reversed course on Wednesday and threw their support behind the plan after securing more money to help people with pre-existing medical conditions. WASHINGTON — House Republican leaders planned to hold a high-stakes vote Thursday on their bill to repeal and replace large portions of the Affordable Care Act after adding billions of dollars to the measure to help cover insurance costs for people with pre-existing conditions.
Representatives Fred Upton of Michigan, an influential voice in Republican health policy, and Billy Long of Missouri, a close ally of President Trump’s, told reporters after a meeting with Mr. Trump on Wednesday that the latest revisions had won them over. Those included $8 billion in additional funds over five years to supplement the insurance of people with pre-existing health problems. The amendment, drafted by Representative Fred Upton of Michigan, secured Mr. Upton’s support as well as the vote of Representative Billy Long of Missouri, two key Republican lawmakers who had come out against the health care legislation earlier this week, warning that it did not do enough to protect the sick.
President Trump blessed the proposal at a White House meeting with both lawmakers as he pressed hard for a vote that could at least ensure House approval of the bill, which embodies one of his key campaign promises. That set up the likely vote Thursday that carries enormous consequences, for his legislative agenda, for Speaker Paul D. Ryan, who has failed twice to bring the bill to the House floor — and for an American health care system that has faced enormous upheaval for years, and the patients who rely on it.
The measure faces a wall of opposition from health care providers, disease advocates and retirees, and has been derided by many Senate Republicans who are all but certain to reject vast portions of it, should it clear the House. But clearing the House is the necessary step to keep alive the Republican promise — seven years in the making — to dismantle President Barack Obama’s signature domestic achievement.
Mr. Upton predicted the bill was “likely” to pass the House, a tremendous reversal of momentum for a measure that has twice been pulled back from a vote for lack of support.Mr. Upton predicted the bill was “likely” to pass the House, a tremendous reversal of momentum for a measure that has twice been pulled back from a vote for lack of support.
Their announcement gave a big lift to Speaker Paul D. Ryan and other Republican leaders who are trying to round up enough votes to push the bill through the House this week. In an interview on a Wisconsin radio station on Wednesday morning, Mr. Ryan expressed confidence in the bill’s chances. Their announcement gave a big lift to Mr. Ryan and other Republican leaders who are trying to round up enough votes to push the bill through the House this week.
“We’ve got some momentum,” Mr. Ryan said. “We’ve got some momentum,” Mr. Ryan told a Wisconsin radio station on Wednesday morning.
Democrats, once confident of another collapse, tried to slow that momentum. The liberal health advocacy group Families USA said another $8 billion would do little to improve so-called high risk pools that would be set up by state governments to help insure people unable to afford insurance on the open market. Democrats and health care groups, once confident of another collapse, tried to slow that momentum. The liberal health advocacy group Families USA said another $8 billion would do little to improve the “high-risk pools” that could be set up by state governments to provide coverage to people with pre-existing medical conditions who could not find affordable insurance in the open market.
Senator Chuck Schumer of New York, the Democratic leader, criticized that plan. “The proposed Upton amendment is like administering cough medicine to someone with stage four cancer,” he said in a statement. “This Republican amendment leaves Americans with pre-existing conditions as vulnerable as they were before under this bill.” The American Medical Association and 10 organizations representing patients, including the American Heart Association and the advocacy arm of the American Cancer Society, reiterated their opposition to the House Republican bill on Wednesday, as did the retirees’ lobby AARP.
How far that $8 billion would go to ensuring that people with pre-existing medical conditions remain covered is not clear. The Upton legislation doesn’t set down any rules for who states would make eligible for the pool, how much care would be covered, or how much individuals could be asked to spend themselves on premiums. “None of the legislative tweaks under consideration changes the serious harm to patients and the health care delivery system” that would result from the bill, said Dr. Andrew W. Gurman, the president of the American Medical Association. The latest changes, he said, “tinker at the edges without remedying the fundamental failing of the bill – that millions of Americans will lose their health insurance as a direct result of this proposal.”
The number of states that opted to create high-risk pools would also influence how far the $8 billion in additional funding would stretch. But a 2010 estimate made by conservative health economists at the American Enterprise Institute, suggested that an adequate high risk pool program for the country would cost between $15 billion and $20 billion a year. More liberal groups have estimated far larger numbers. Senator Chuck Schumer of New York, the Democratic leader, also criticized the latest version of the legislation. “The proposed Upton amendment is like administering cough medicine to someone with stage four cancer,” he said in a statement. “This Republican amendment leaves Americans with pre-existing conditions as vulnerable as they were before under this bill.”
But with Mr. Upton and Mr. Long back on board, Republican leaders appeared ready to call another vote, after the collapse of their measure in March. Victory is far from assured. Another Republican from a Democratic-leaning district, Representative Carlos Curbelo of Florida, seemed to indicate he was leaning against the American Health Care Act, as the Republican legislation is known, although he stood ready to be persuaded by Mr. Upton. If House Republicans can pass the bill, it would be a moment of redemption for both Mr. Ryan and Mr. Trump, who in March suffered a resounding political defeat when they failed to muster the votes to win approval of an earlier version of the repeal bill.
And pressure from health care providers, disease advocacy groups and others remains intense. The advocacy arm of the retirees’ lobby AARP tweeted that the Upton amendment was an “$8 billion giveaway to insurance companies; won’t help majority of those w/preexisting conditions. We remain opposed.” The Affordable Care Act generally requires insurers to accept all applicants and prohibits them from charging higher premiums because of a person’s medical condition. Conservatives argued that this and other requirements of the 2010 health law drive up insurance costs. The House Republican bill to roll back the Affordable Care Act generally requires insurers to charge higher premiums for one year to people who allow their coverage to lapse.
Representative Nancy Pelosi of California, the House minority leader, said the money would be a small fraction of what is needed. At the insistence of conservative lawmakers, House Republican leaders agreed to let states apply for waivers allowing insurers to charge higher rates based on a person’s “health status.”
“It’s time for the Republicans to abandon their moral monstrosity and pull this bill,” she said. The original version of the Republican repeal bill would establish a $100 billion fund that states could use to help people pay for health care and insurance from 2018 to 2026. House leaders added $15 billion last month to help insurers pay claims for their sickest customers. Mr. Upton’s proposal would provide $8 billion over five years on top of that.
If the effort fails, it will greatly weaken the president’s hand on Capitol Hill and cast a shadow across the rest of his legislative agenda, especially the deep tax cuts and rewrite of the tax code that he has proposed — and promise to be no easier to tackle than health care. How far that $8 billion would go in providing coverage for people with pre-existing conditions is not clear. Mr. Upton’s proposal does not specify who would be eligible, how much of their costs would be covered or how much they would be expected to contribute in premiums.
Mr. Upton, the former chairman of one of the House committees that drafted the American Health Care Act, has a long history of negotiating with Democrats on health care measures, and his support could prove crucial. How many states would seek waivers is difficult to predict.
He said on Tuesday that the latest version of the health care bill “torpedoes” protections for people with pre-existing medical conditions. But the fight over pre-existing conditions overshadowed a major reason the Congressional Budget Office estimated that the original bill would leave 24 million more Americans without health insurance after a decade: a rollback of the Affordable Care Act’s Medicaid expansion in states that adopted it. The House plans to vote for the latest version before C.B.O. can finish a fresh assessment of its cost and impact.
Trying to win their votes on the health bill, Mr. Trump met Wednesday with Mr. Upton and Mr. Long. Representative Michael C. Burgess of Texas and Representative Greg Walden of Oregon, the current chairman of the Energy and Commerce Committee who succeeded Mr. Upton as the head of that powerful panel also attended the meeting. The deal-making appears to have worked. Representative Joe L. Barton, Republican of Texas, predicted that his state “would lead the parade to opt out of all the federal mandates” in the Affordable Care Act.
Last-minute spending increases and special provisions in 2009 and 2010 to win over Senate Democrats to the Affordable Care Act had outraged some conservatives who fumed at “the Cornhusker kickback” and the “Louisiana Purchase.” But so far, the Upton amendment has prompted no such anger on the Republican side. But Representative Carlos Curbelo, Republican of Florida, said: “I would highly doubt that any governor, especially the governor of a large state like Florida, would seek a waiver. I just don’t think that any state would want to carry the burden of managing health care more than they already do, through Medicaid.”
Republican leaders now hope to get the bill through the House by Thursday, before lawmakers go home again and face pressure from constituents. Party leaders are facing an onslaught of advocacy groups and Democratic attack ads saying the bill would harm the nation’s most vulnerable citizens. Even a late-night talk show host, Jimmy Kimmel, joined with an emotional appeal. Mr. Curbelo illustrated the fluid politics swirling around the repeal bill. In a Twitter post on Thursday morning, he said he had just told House Republican leaders that the bill “in its current form fails to sufficiently protect Americans with pre-existing conditions.” In a late afternoon interview, he said, “I do not yet have a position on the bill.” He wanted to hear more from Mr. Upton, a respected Republican voice on health care.
A tearful Mr. Kimmel on Monday night told the story of his infant son, Billy, who was born with heart defects and had surgery. Mr. Kimmel pleaded with Congress not to undermine the Affordable Care Act’s ban on discrimination against people with pre-existing conditions. The Affordable Care Act set up a special health insurance program for people with cancer, heart disease and other serious illnesses, to provide coverage until 2014, when insurers were forbidden to discriminate against people based on their health status. Claims far exceeded Obama administration estimates, exhausting most of the $5 billion provided by Congress.
After Mr. Kimmel’s monologue went viral, former President Barack Obama weighed in on Twitter, writing: “Well said, Jimmy. That’s exactly why we fought so hard for the ACA, and why we need to protect it for kids like Billy.” The average cost per enrollee was more $32,000 a year in 2012, according to a federal report on the program, and the cost varied widely among states, from a low of $4,300 to a high of $171,900 per enrollee.
House Republican leaders are also fighting against the clock. The House is scheduled to be in recess beginning on Friday and is not set to return until May 16. Republicans who are on the fence are likely to get an earful from their constituents. Mr. Upton and Sean Spicer, the White House press secretary, said they believed that the money in the bill would be adequate. “It’s our understanding that the $8 billion over the five years will more than cover those that might be impacted and as a consequence, keeps our pledge for those that, in fact, would be otherwise denied because of pre-existing illnesses,” Mr. Upton said at the White House.
“I think it’s imperative that we have a vote before we leave for a week,” Representative Mark Meadows, Republican of North Carolina and the chairman of the conservative House Freedom Caucus, said on Tuesday. To qualify for assistance under the Upton proposal, a person would have to live in a state with an approved waiver, have a pre-existing condition and be uninsured because of a failure to maintain “continuous coverage.”
Republicans were clearly divided over the adequacy of the bill’s protections for people who are sick or disabled. At the heart of the debate is an amendment to the repeal bill proposed by Representative Tom MacArthur, Republican of New Jersey. The amendment, which won over the Freedom Caucus last week, would give state governments the ability to apply for waivers from the existing law’s required “essential health benefits,” such as maternity, mental health and emergency care, and from rules that generally mandate the same insurance rates for people of the same age, regardless of their medical conditions. The House Democratic leader, Nancy Pelosi of California, said the money was a pittance, compared with the likely need. “It’s a joke,” she said. “It’s a very sad, deadly joke.”
With a waiver, states could permit insurers to charge higher premiums based on the “health status” of a person who had experienced a gap in coverage. To qualify for a waiver, a state would have to have an alternative mechanism, like a high-risk pool or a reinsurance program, to provide or subsidize coverage for people with serious illnesses. The latest amendments to the bill amount to “a hoax on pre-existing conditions,” Ms. Pelosi said, adding: “If Republicans have their way, Americans with pre-existing conditions will be segregated into high-risk pools where they face soaring costs, worse coverage and restricted care.”
“States can’t leave people with pre-existing conditions high and dry,” Mr. MacArthur said Tuesday, defending his proposal.
But the MacArthur amendment prompted a coalition of health care groups, including the American Medical Association, and organizations like the American Heart Association and March of Dimes to urge the House to vote against the bill. That has distressed some Republicans.
Representative Tom Rooney, Republican of Florida, said he was “leaning yes” on the repeal bill, but agonizing over how to explain his vote to constituents.
“I have a lot of people who call my office on a daily basis who are extremely angry,” he said. “It’s not just because I’m a Republican, but because they are sincerely scared.”
Many people with pre-existing conditions fear that they may lose coverage and “are going to die because of a vote we might be taking,” Mr. Rooney said.
Members of the Freedom Caucus did not seem interested in compromising much further.
“The pre-existing condition debate and discussion in Congress, far as I’m concerned, is over,” Representative Scott Perry, Republican of Pennsylvania and a member of the Freedom Caucus, said Tuesday. “They are covered; we acknowledge it; we provide for it; it is done.”