Q: Is the bill that passed the House today intended to repeal the Affordable Care Act?
Not entirely. In the seven years since a Democratic Congress and the Obama administration pushed through the ACA, the House has taken more than 60 votes to repeal all or part of it. But today’s vote was a first-stage effort, with the bill intended — at least originally — to address only those parts of the sprawling law with budgetary implications. It is designed that way so the Senate will have an easier time passing the legislation under a “reconciliation” process that allows bills with budgetary impact to be approved by a simple majority, rather than a filibuster-proof 60-vote majority.
Q: So what does the House Republican bill include and exclude?
In broad strokes, the legislation has a lot of financial aspects. For instance, it would substantially reduce the funding for subsidies that the ACA provides to most people seeking health coverage through insurance marketplaces the law created. It also would make other changes to those subsidies in ways that, overall, would help younger adults and increase premiums for older people. The bill also would eliminate several taxes the ACA created to help pay for its provisions, including on health insurers and affluent Americans.
The House GOP plan would not eliminate the requirement that most Americans carry health insurance. Instead, it would get rid of the penalty imposed for not having insurance and would create a new deterrent for having a gap in coverage: a one-year 30 percent surcharge that insurers could tack onto their rates.
Q: Would this affect the number of people with insurance in the United States?
Yes. According to an estimate of the bill's original version by the Congressional Budget Office, 24 million more people would be uninsured by 2026. The CBO did not update that forecast since House Republicans tinkered with aspects of the legislation to secure enough GOP votes for it to narrowly pass.
Q: What would happen to the ACA's marketplaces?
The bill would not end the federal and state marketplaces that, since 2014, have been a route to insurance for people who cannot get affordable health benefits through a job. However, while the ACA's premium subsidies can be used only within these marketplaces, the bill's new tax credits could also be used outside them. A looming question is what effect the House's vote on Thursday will have on insurers' willingness to stay in the marketplaces for 2018 — a particularly pressing question since spring is generally when insurers need to tell states whether they are in or out for the following year.
Q: How would the bill change protections for people with preexisting conditions?
Under the ACA, insurers are prohibited from denying coverage to individuals based on preexisting medical conditions, such as cancer, high blood pressure or asthma. And the ACA requires insurers to offer “community rating,” meaning they cannot charge those with costly medical conditions more than they charge other consumers in the general insurance pool.
But an amendment written last week by Rep. Tom MacArthur (R-N.J.) would allow states to obtain a waiver from the Health and Human Services Department so they could charge customers with preexisting conditions more than other people. If HHS did not respond to a state’s waiver request within 60 days, the requested change would automatically go into effect.
Health experts predict that the result would be a sharp rise in premium increases for those with medical problems. Before the ACA became law, individuals with chronic diseases paid several times as much as others — if they could afford or be approved for a policy in the first place.
Concerned about the effect the MacArthur amendment would have on those with long-standing medical conditions, GOP Reps. Fred Upton (Mich.) and Billy Long (Mo.) crafted a provision Wednesday to provide $8 billion to help these patients pay for increased premiums and out-of-pocket costs. That money would be spread among whichever states decided to let insurers return to the practice of charging higher rates to certain customers. As part of a waiver application to HHS, a state would be required to include a "risk-sharing plan" — either recreating a so-called high-risk pool, which many states tried before the ACA — or designing a subsidy program for residents with preexisting conditions.
Q: Does the bill treat domestic violence, sexual assault, Caesarean section and postpartum depression as preexisting conditions?
The bill does not spell out either what sort of preexisting conditions insurers may take into account if states seek a waiver from the existing federal law. But in the past, some insurers had identified domestic violence, sexual assault, Caesarean section and postpartum depression as grounds for either denying coverage or charging higher premiums.
“When you can’t predict the future," Alina Salganicoff, vice president and director of women’s health policy at the Kaiser Family Foundation, said Thursday, “one looks back to see what the prior experience has been.”
Q. What would happen to “essential health benefits”?
The ACA compels insurers to include a specific set of benefits in all health plans sold to individuals and small businesses. The House bill would change that, leaving it up to each state whether to preserve this rule or create its own set of coverage requirements — or no requirements at all. A recent Washington Post-ABC News poll found wide public support for leaving in place both this federal rule and the one regarding preexisting conditions.
Q: Would the bill affect the ACA’s requirement that all private health plans include no-cost contraception coverage?
No, but the executive order President Trump plans to issue Thursday will trigger a regulatory process to roll back this requirement. It remains unclear what sort of “regulatory relief,” as White House officials have described it, will be provided to groups that have religious objections to covering certain forms of birth control. Houses of worship are already exempt, but religious nonprofits have been required to seek an accommodation to opt out of providing free contraceptive coverage for their employees. (They can do this by either notifying their insurer, a third party administrator or the federal government of their objection, at which point the insurer must provide the coverage.)
According to a Kaiser Family Foundation survey, roughly 10 percent of large nonprofits have asked for an accommodation under the current law. “It’s not an insignificant amount of women,” Salganicoff said. She cautioned that it is difficult to predict how Health and Human Services would change the current rule and whether this accommodation provision would continue to exist if employers were given the chance to opt out entirely.
Q: Would adult children (up to age 26) still be able to remain on a parent’s health plan?
Yes. This is one of the few facets of the Affordable Care Act that both Republicans and Democrats agree on, because it is so popular with the public.
Q: Would Medicaid be affected?
Absolutely. Republicans' bill would cut $880 billion from the Medicaid program over the next decade, according to the most recent CBO estimate. This program provides health coverage for low-income Americans and helps pay for long-term care for people with disabilities and seniors.
Under the ACA, 11 million people have gained coverage through the ACA's Medicaid expansion. For the next few years, the 31 states that chose to broaden their programs could keep going with that, but new people eligible under the expansion could not enroll.
Then, starting in 2020, Medicaid would switch nationwide to a very different method of federal payments, breaking with its history of paying a certain proportion for everyone enrolled and moving to a system in which each state would be given a certain amount per person — a change that critics predict would starve the program as time goes by as well as affect beneficiaries' access to care.
Q: What are the budgetary implications of the recent changes?
The CBO has not had time to review the changes Republicans have made to the bill, so it will not be providing a budget estimate before the House votes on the measure. Before Republicans added $8 billion this week to sway lawmakers concerned about the bill's impact on coverage for preexisting conditions, the Committee for a Responsible Federal Budget said the alterations could save up to $5 billion or cost as much as $265 billion. The uncertainty reflects a big unknown: how many states will seek waivers to change their benefits packages or the ratings rules that insurers must comply with under current federal law.
According to a CBO estimate issued in late March, the House GOP plan would cut the federal deficit by $150 billion between 2017 and 2026.
Q: How would the bill affect public health programs?
The GOP bill would eliminate funds for fundamental public health programs, including for the prevention of bioterrorism and disease outbreaks, as well as money to provide immunizations and heart-disease screenings. It would gut something called the Prevention and Public Health Fund, which provides almost $1 billion annually to the Centers for Disease Control and Prevention. That fund accounts for about 12 percent of CDC’s total budget. If the GOP bill eventually becomes law, those public health monies would be eliminated starting in October 2018.
A significant portion of those funds, about $625 million a year, goes directly to state and local health departments. If prevention funding is lost, public health advocates warn that Americans will be at greater risk for vaccine-preventable disease, food-borne infections and deadly infections contracted in hospitals. One of the biggest recipients of the prevention fund is the CDC’s immunization program, which last year received $324 million. The money is sent directly to states and local communities to improve immunization infrastructure, such as registries that allow providers to know which patients have received what vaccines.
Q: What are the odds of the House bill passing the Senate?
Uncertain. Before the Senate could even consider it, the bill would need to pass muster with the Senate parliamentarian, who would scrutinize it to ensure it fits within the chamber’s rules on considering only matters with budgetary implications under the reconciliation process. Recent changes to the House bill — such as giving states power to decide whether to keep or jettison a set of essential health benefits that the ACA requires many health plans to include — could be an obstacle.
If and when the bill gets past the parliamentarian, many senators are wary especially of the changes the legislation would make to Medicaid.
Lena Sun contributed to this report.