They Don’t Have the Votes

As of 3:30pm, the House is in recess and the vote has been postponed. A Republican conference meeting is underway. According to a spokesperson for President Trump, “we just pulled it.”

Earlier today, Speaker of the House Paul Ryan (R-WI) informed President Trump that he does not have the votes to pass the American Health Care Act (AHCA) in the House. In order to pass, no more than 22 Republicans could vote against it. The NYtimes vote tracking page at 3pm today, counted 33 Republicans as no votes, with an addition 9 leaning no, while the Washington Post reports 36 no votes, and another 15 leaning no. This comes on the heels of yesterday’s Quinnipiac poll, reporting that only 17 percent of Americans support the AHCA, while 56 percent oppose it.

The debate on the House floor ceased at 3:30pm. What’s next for the AHCA? Will they cancel the vote entirely?

To understand what some of the behind-closed-doors debates have been about this week, you need to understand the sources of opposition within the Republican party.

Opposition to the AHCA from Republicans

There have been two primary groups opposing the American Health Care Act (AHCA) within the Republican party: the Freedom Caucus and the more moderate wing, that Vox has called, the “coverage caucus.”

The basic argument from the perspective of the Freedom Caucus is that the original version of the AHCA keeps too much of Obamacare in place. Instead, they requested that more of the regulations and insurance mandates (e.g., essential health benefits) need to be repealed in an effort to lower health insurance premiums.

The ten essential health benefits created by the Affordable Care Act (ACA) include: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care. This debate has led to the now infamous photo posted by Vice President Mike Pence of a group of men debating these ten essential health services, without a woman in the room. However, getting rid of the essential health benefits alone will not satisfy the Freedom Caucus enough to get them to a yes.

On the other side of the opposition, the more moderate wing of the Republican party is concerned about every analysis which suggests that millions of Americans—especially older, sicker Americans—will  lose coverage under the AHCA.

The Amendments

In an effort to appease both sides (a difficult task, for sure), 11 changes were made to the AHCA. Eight of these changes were made on Monday through technical and policy changes in the manager’s amendment, while an additional three changes were made on Thursday. These eleven changes include:

For the Freedom Caucus:

  1. Eliminating the requirement that 10 essential health benefits be included in plans sold in the individual and small business markets. States can choose the basic benefits required for health insurance, including maintaining this list of ten, reducing it, or eliminating all requirements.
  2. End the enhanced match for federal funding for the Medicaid expansion sooner. This provision would only allow enhanced matching rates for Medicaid expansion in states that have already expanded, as of March 2017.
  3. States could choose to add work requirements for their Medicaid population. States that choose this option would receive a 5 percentage point higher match rate from the federal government to cover additional administrative costs.
  4. Instead of only having the option of per capita caps in Medicaid, states could also choose to block grant their Medicaid program. Choosing to block grant the state Medicaid program would enable greater flexibility in determining benefits.
  5. Move up the repeal of ACA taxes on health insurers, branded prescription drugs, medical devices, and tanning beds to 2017 instead of 2018.

For Moderates:

  1. States could use the Patient and State Stability Fund to cover maternity and newborn care. Additional funding of $15 billion was set aside to make this possible.
  2. Delay repeal of 0.9% Medicare tax on higher income earners for six years. Maintaining this tax on higher income earners would result in about $63 billion in revenue, and fund the maternity and newborn care provision above.
  3. Increase the rate at which the per capita funding amount for the Medicaid program would go up from year to year for the elderly and disabled population. This provision would not apply to children and other adults.
  4. Creates a new reserve fund of about $85 million to provide additional premium tax credits for older adults (ages 50-64). The Senate would need to work out the details.

An additional two provisions were targeted at unique circumstances in New York and Illinois:

  1. Incentivize states (i.e., New York) to stop requiring that county taxes contribute to the state Medicaid program.
  2. Illinois would be allowed to adjust its 2016 Medicaid expense report, which would allow more money to flow to the state when the Medicaid program converts to a per capita cap program.

We do not yet know if these amendments will go down as mere blips in the story of the Republicans’ 2017 attempt to repeal and replace the Affordable Care Act, or if they still have life to live.  Speaker Paul Ryan is due to have a news briefing at 4pm today. Tune in.