CongressBeginsWorkonAffordableCareActRewrite
March2017
Having campaigned long and hard to “repeal and replace ‘Obamacare,’” the House of
Representatives’ Republican leadership began advancing its revisions to federal health insurance
legislation in early March. The initial drafts of the “American Health Care Act” (AHCA) began
seeing the light of day on March 8, as this legislation began working its way through the two House
committees with greatest jurisdiction over health care legislation: the Energy and Commerce
Committee and the Ways and Means Committee.
This legislation has attracted a lot of controversy and media attention, and may face an uncertain
future. Community transportation providers and stakeholders will find a few items of potential
interest or concern in the AHCA, but it’s at least as important to see how this legislative process
plays out, since it is likely to be followed soon by the White House’s pledge to advance a
comprehensive infrastructure investment bill, and by the desire of many in Congress to begin
working on significant adjustments to the Internal Revenue Code.
TheAmericanHealthCareActandTransit
First of all, it’s important to note that everything in this draft legislation is subject to change as it
works its way through Congress. This legislation could advance with minimal change, it could be
substantially revised, and there’s even a chance that it never arrives anywhere near the White
House for possible enactment.
With that very important caveat, the initial draft of the AHCA has the possibility of affecting
community and public transportation providers in three ways:
1. By removing the “employer mandate” under which the Affordable Care Act requires many
employers to make health insurance coverage available to all their employees who work
more than 30 hours a week, the AHCA could remove the costs of providing health
insurance from many employers’ staffing plans and decisions.
2. By removing the category of Medicaid eligibility for people whose income is up to 138
percent of the poverty line (in those states that adopted this “Medicaid expansion” option
under the Affordable Care Act), beginning in 2020, there will be many individuals,
including some who have been depending on non-emergency medical transportation
(NEMT) for access to their Medicaid-covered health care services, who begin dropping
from the Medicaid rolls in those states.
3. By creating a fundamental change in the methodology by which the federal government
allocates Medicaid funds to the states, starting in 2020, it’s likely that many states would
have to take a fresh look at the ways in which they provide Medicaid-funded services, which
has tremendous – but incredibly uncertain – potential to change the game for NEMT.
As drafted, there is nothing in the AHCA that directly changes NEMT. Were it to pass in the
same form as its was introduced, the AHCA would make no change whatsoever to the
requirement that states provide medical assistance to all eligible individuals in their state, that the
medical assistance has to include all the specific health care services currently enumerated in
statute (there is a lot of debate over the funding of abortion services, but federal law long as
prohibited the use of Medicaid funds for abortions in most cases), and there is no change in the
statutory requirement that Medicaid be available statewide. Most community transportation
providers and partners will recognize that this “statewideness” requirement is why the federal
courts and the Centers for Medicare and Medicaid Services (CMS) require states to address NEMT
in their state Medicaid plans.
WhatHappensNextWithThisHealthCareBill?
As of mid-March, the AHCA was working its way through House committees of jurisdiction, and
House GOP leadership was promising a quick arrival on the House floor, in their efforts to seek
quick passage of this legislation. It has drawn partisan opposition, which is not a surprise to
anyone who’s been watching Congress in recent years, but this draft legislation also has drawn
criticism from several divergent caucuses of House Republicans, some of whom feel the legislation
“does not sufficiently repeal ‘Obamacare,’” and some of whom are concerned that it goes too far in
what it does for various constituencies affected by this legislative proposal. As a result, it appeared
that the bill might be able to garner enough votes to pass the House.
If some version of the AHCA arrives in the Senate, it will be handled under the rules of what’s
called “budget reconciliation,” which means that it needs only a simple majority (i.e., 51 votes) to
pass. As with the House, no Democrats in the Senate have indicated they will vote in favor of the
bill. It the vote were a strict party-line vote, the 52 Republicans in the Senate could assure likely
passage, but already there have been 4 GOP Senators who say they oppose the bill because of the
impact its Medicaid revisions would have on their states, and there are another 3 GOP Senators
who say they will oppose the bill because it does not go far enough, in their opinions, of “repealing
‘Obamacare.’”
The White House and House GOP leadership have been working to win over a sufficient number
of GOP votes to assure passage in the House and Senate, but it’s far from clear whether this will be
successful, nor is it at all clear what amendments will be made to the legislation in order to seek
secured passage.
WhatDoestheHealthCareBillAugurforthePresident’sInfrastructurePlan?
The AHCA is the first effort in this session of Congress to begin legislating an item that long has
been important to many in the Republican Party, and is the first legislated item that was a
campaign pledge by the current President. The ability of Congress and the White House to get this
initiative enacted will show how well they can address other high-profile, and possibly high-dollar,
items of legislation.
That’s important because the White House is beginning to tee up the “infrastructure” bill that was
another major campaign pledge. During his campaign, Mr. Trump promoted a $1 trillion initiative
that largely would be financed through some form of leveraged public-private partnerships. Many
of the arguments and points of concern raised by Congressional Republicans over the AHCA are
likely to be raised again with this proposal, depending on how and what is presented. Some
members of Congress have looked at this concept, and thought it sounded to them too much like
a replay of the American Recovery and Relief Act (ARRA, or the “stimulus bill”) of 2009. Others
look at the price tag, and voice concerns that the direct federal investment – even in public-private
partnerships – will be too great for the budget to afford. Any many Congressional Republicans
look at what the President has suggested, and see this as an attractive strategy to spur the economy,
increase production and increase employment through these infrastructure investments.
So, just as we’re starting to see with the American Health Care Act, it will be interesting – and
possibly of critical importance – to see how these disparate corners of the House and Senate
Republican caucuses rally around (or fail to rally around) the infrastructure proposal and other
forthcoming items of significant legislation.