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May 4 2017, 2:44 pm ET

House Narrowly Passes GOP Health Care Bill

by Leigh Ann Caldwell

By the slimmest of margins, the House of Representatives passed the Republican plan to replace Obamacare Thursday afternoon, sending the measure to a skeptical Senate where it will be almost certain to take on a completely different form. Republicans passed the bill by a vote of 217 to 213, just one vote over the 216 needed

Republicans had been working to piece together a GOP-only coalition of votes ever since their attempt to repeal and replace much of the Affordable Care Act failed nearly two months ago and came into the vote with just 21 votes to spare.

House Speaker Paul Ryan took to the floor ahead of the vote to argue that Obamacare was failing. "We can continue with the status quo or we can put this collapsing law behind us and end this failed experiment," he said.

Ryan Makes Final Plea on House Floor Before Health Care Vote 2:13

Following the vote, House Republicans boarded buses for a trip down Pennsylvania to participate in a celebratory press conference with President Donald Trump, who many members credited for helping get the bill across the finish line.

"This is a good day for the American people and the president of the United States. He personally engaged in a real way to make a difference," said Rep. Mark Meadows, R-N.C. before the vote. Meadows had been working his conservative members to agree to the measure as the vote neared. Trump had threatened to run a primary against Meadows and fellow conservatives after the bill’s failure in March.

Related: Here’s What You Need to Know About the GOP Health Care Bill

Last minute deals, including promises to some members on future legislation and an additional $8 billion for people with pre-existing conditions in the current bill, helped to get squeamish moderates on board, a move that opened the doors for leadership to find enough votes.

The final tally, however, was razor-thin because it was a politically risky vote for many moderates in swing districts who could have tough re-elections in 2018 who are wary of campaign ads saying they voted to take away coverage for people with pre-existing conditions.

Democrats in the House chamber, hopeful that the issue could help them win back the majority in the midterm elections, waved at GOP members after the vote and sang, "hey, hey, hey — goodbye."

After all the wrangling to get through the house, the bill is sure to undergo extensive changes in the more moderate Senate.

Sen. Bob Corker, R-Tenn, said that the House bill has "zero" chance of passing the Senate.

"That’s not the way it’s going to work. To be honest," Corker said on MSNBC’s "Morning Joe." "People are going to want to improve it. I don’t see any way that it goes back in the form that it comes."

The Senate, however, will not need any Democrats to pass it because they are using a procedural mechanism that allows the bill to pass the Senate to pass with just 51 votes instead of the usual 60-vote threshold. There are 52 Republicans in the Senate.

The House measure came to the floor without an updated accounting of how much the bill will cost or its impact. The last assessment, which was done before the bill was altered, said that 24 million people would lose insurance, it would save $300 million and premiums would go down ten percent after ten years.

Rep. Barry Loudermilk, R-Georgia, said that having no updated CBO score is slightly concerning.

"It is a concern, but at this point we have to move forward. The American people are clear they want this done, so I think we have to strike when the iron’s hot," he said.

House Passes GOP Health Care Bill with 217-213 Vote 3:27

Consumer advocacy groups have expressed concern for the bill, saying that it won't adequately protect patients. Meanwhile, the conservative, small-government political groups such as Club for Growth and Heritage Action have come out in support of the measure.

Rep. Raul Labrador, R-Idaho, one of the most conservative members of Congress, said he will vote for the bill. But when asked if he can guarantee that no one would lose coverage under the GOP plan, he could not.

"What I can guarantee is that more Americans will be helped by this plan than Obamacare has helped," he said. "More people will have their premiums lowered, more people will have lower out of pocket costs more people will have access to these high risk pools."

The legislation was made more conservative throughout the process to appeal to members like Labrador who wanted nothing short of a complete repeal of the Affordable Care Act.

Here are the key measures in the House bill:

  • Mandates: It guts the IRS requirement in Obamacare that people with purchase health insurance or face a fine.
  • Tax credits: The bill replaces subsidies for people to purchase insurance in the individual market in the Affordable Care Act based on income with refundable tax credits based on age. The impact is that it will provide more people with assistance but with fewer dollars, especially for the older Americans.
  • Medicaid: The Medicaid expansion is frozen immediately and in two years the states can start to adopt either a block grant for the program or a new formula based on population instead of need. In an attempt to make the bill more conservative, work requirements have been added for most able-bodied recipients who aren't pregnant or caring for a child under 6.
  • High risk pools: The bill provides $130 billion to states over ten years for high risk insurance pools to cover the most expensive to insure. A new amendment by Rep. Fred Upton of Michigan adds an additional $8 billion to assist people with pre-existing conditions.
  • State waivers: States can obtain waivers so insurers don't have to offer robust benefits packages that include maternity care and mental health coverage. Waivers can also be obtained to charge sicker people and people with pre-existing conditions more. Those people would most likely then go into the high risk insurance pools.
  • Taxes: It repeals every Obamacare tax including the .9 percent tax on couples making more than $250,000 and a 3.8 percent tax on investment income.
  • Health Savings Accounts: The measure increases the allowable contribution limits of Health Savings Accounts
  • Other: It keeps the Obamacare provision that people under the age of 26 can stay on their parents' insurance.
Leigh Ann Caldwell
Leigh Ann Caldwell
Contributors Alex Moe, Frank Thorp V and Marianna Sotomayor
First Published May 4 2017, 12:31 pm ET
May 4 2017, 2:09 pm ET

What Are Pre-Existing Conditions and What Would the GOP Bill Do?

by Maggie Fox

A young lawyer who died after a prolonged seizure. A young woman who died of cardiac arrest. Diabetes patients who cannot get insulin. Dr. Leana Wen said cases like these will happen again if the new version of the American Health Care Act (AHCA) passes Congress.

All these patients had what the insurance industry calls pre-existing conditions — diseases, injuries or conditions that affected a patient before he or she got a health insurance policy.

Image: Planned Parenthood Funding Threatened By GOP Legislation
Doctors say the new health care bill could have dire consequences for patients with pre-existing conditions. Joe Raedle / Getty Images

"Right now, the Affordable Care Act protects those with pre-existing conditions," said Wen, who was an emergency room physician before she became Baltimore city health commissioner. That would change under the AHCA.

"States could allow insurers to set much higher rates for patients who have a pre-existing condition. That’s terrifying, because patients could in essence be priced out of coverage," Wen told NBC News.

Related: Here’s What you Need to Know About the Health Care Bill

Pre-Obamacare, health insurers routinely refused to cover people for such conditions, or charged extremely high premiums, co-pays and deductibles.

“This is literally a life or death issue.”

Companies argued it was the only way to prevent people from waiting to buy insurance until they were already sick. Some supporters of the AHCA say it’s about personal responsibility. After all, why should all the customers of a health insurance plan pay for people who wait until they are sick or injured to buy coverage?

But medical groups from the American Medical Association to the Juvenile Diabetes Research Foundation (JDRF) say health insurers often made up their own definitions of pre-existing conditions. And they often denied coverage to people born with such conditions, or who developed them in childhood.

"For many years, the type-1 diabetes community had to battle with insurers that were allowed to deny coverage or charge significantly more to cover people with pre-existing conditions and we want to ensure that our community does not have these same battles in the future," JDRF said in a statement.

The 2010 Affordable Care Act changed that by requiring health insurance companies to accept everyone who applied for coverage. In return, the ACA required that just about everyone get health insurance or pay a special tax.

The idea is to mix healthy people together with sicker people, with everyone paying premiums, so that the companies have enough money to pay out everyone’s claims.

Before Obamacare, pre-existing conditions that cost people coverage, or led to very high premiums, included:

  • Pregnancy
  • Diabetes
  • Heart disease
  • Genetic conditions
  • Injuries
  • Epilepsy
  • Cancer
  • Mental disorders

Wen said she saw the fallout on a daily basis.

"I remember seeing a patient in his mid-20s who had a seizure disorder," she said. "He would have had to pay like $8,000 a month for health insurance. "

The man, a lawyer with young children, had to go without health coverage, which meant he could not get medications to control his seizures. "He ended up in the ER one day after having a seizure for an hour. We couldn't stop the seizure for another hour," Wen recalls.

He never came out of his coma.

Wen described the case of a young woman with a congenital heart condition, also in her 20s, who was refused health insurance coverage. "She stopped taking her medications, and came in while in cardiac arrest," Wen said. "This is literally a life or death issue."

The new version of the AHCA doesn’t specifically allow insurers to refuse coverage to anyone. It lets states — which regulate health insurance — ask permission to opt out of the requirement, with the Health and Human Services Department deciding who can do it.

It also allows states to set up so-called high-risk insurance pools, which are policies to cover people with pre-existing conditions who find it too hard to get health insurance. And it provides federal money to help states pay for them.

But experts say high-risk pools never worked before.

Related: Medicaid Is Trendy With Death of GOP Health Bill

"High-risk pools are not a new idea. Prior to the enactment of the Affordable Care Act, 35 states operated high-risk pools, and they were not a panacea for Americans with pre-existing medical conditions," American Medical Association (AMA) President Dr. Andrew Gurman said.

"The history of high-risk pools demonstrates that Americans with pre-existing conditions will be stuck in second-class health care coverage — if they are able to obtain coverage at all."

Other groups agreed.

"Previous state high risk pools resulted in higher premiums, long waiting lists and inadequate coverage," a coalition of 10 medical groups, including the American Cancer Society Cancer Action Fund, the American Diabetes Association and the National MS Society, said in a joint statement opposing the AHCA.

"State high-risk pools featured premiums above standard non-group market rates — with most states capping them at 150 percent to 200 percent of standard rates. Many also featured high deductibles, some $5,000 or more," the nonpartisan Kaiser Family Foundation said in a statement.

Related: Obamacare Creators Tell GOP We Told You So

"Almost all high-risk pools imposed lifetime limits on covered services, and some imposed annual limits," it added. "Some states capped or closed enrollment." Overall, these high-risk pools lost $1.2 billion in 2011.

Health consultancy firm Avalere released an estimate Thursday showing that the $23 billion allocated by the new AHCA to help cover people with pre-existing conditions would only pay for 110,000 of them. "Approximately 2.2 million enrollees in the individual market today have some form of pre-existing chronic condition," Avalere says in its report.

"Given the amount of funding in the bill, the program can only afford a few small states to opt into medical underwriting," said Caroline Pearson, senior vice president at Avalere. "If any large states receive a waiver, many chronically ill individuals could be left without access to insurance."

There’s another reason medical groups oppose the new AHCA. It would let states ask to redefine "essential benefits" — the conditions that must be covered by plans.

“This is not about people paying a few dollars more a month.”

"The Affordable Care Act included emergency services as an essential health benefit and any replacement legislation must do the same. Patients can’t choose where and when they will need emergency care and they shouldn’t be punished financially for having emergencies," the American College of Emergency Physicians said in a statement.

Wen said one ER visit could bankrupt someone without this protection.

"This is not about people paying a few dollars more a month," she said. "These are preventable deaths and I saw them every day in the ER."

Maggie Fox
Maggie Fox

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