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Preexisting Condition: How Health Care Wrangle May Play Out Over Obamacare Repeal

| May 4, 2017

paul ryan obamacare dismantling

It’s Paul Ryan’s battlefield. (Tony Alter)

Note: the House passed the ACA-repeal bill today, 217-214, but the bill’s fate in the Senate is uncertain.

The House may pass its bill to repeal and replace parts of the Affordable Care Act. But Republicans’ pathway to fulfilling their seven-year effort to undo the federal health law is getting narrower by the day.

“As of now, they still don’t have the votes,” said Rep. Pete King (R-N.Y.) as he was leaving a meeting of GOP members Tuesday. King has been a target for those pushing both for and against the bill.

The latest snag is over whether people with preexisting health conditions should have guaranteed access to affordable coverage, as the ACA mandates. An amendment that would let states waive some of those requirements has garnered the votes of reluctant conservatives but left more moderate Republicans concerned.

By Wednesday, however, the combination of pressure from House leaders and President Donald Trump himself seemed to be turning at least some votes. Following a White House meeting, Rep. Fred Upton (R-Mich.), a former chairman of the House committee that handles most health issues, said he would vote for the bill if it added an additional $8 billion to help those with health problems pay for coverage. That same promised amendment also changed the vote of Trump supporter Rep. Billy Long (R-Mo.), who said earlier in the week he planned to vote against the measure.

House leaders stressed that they are still working to muster a majority to pass the bill, which was originally scheduled for a full floor vote in March.

Here are some possible ways the effort could play out.

1. The House passes its bill soon.

Approval in the House would send the measure to the Senate, where the fight will be very different. Congress is using a special budget procedure that allows the bill to pass with 51 votes. There are only 52 Republicans in the Senate, so they can’t afford to lose more than two GOP votes, assuming every Democrat opposes the measure. In that case, Vice President Mike Pence would be needed to break a tie.

While this special procedure makes the bill easier for Republicans to pass, the Senate’s budget “reconciliation” process must follow a series of specific rules that exclude provisions that don’t directly affect the federal budget.

Various parts of the House bill, including a recent change to let states waive some coverage rules that has ignited concerns about preexisting conditions, have been mentioned as possible violations of those Senate rules and would have to be taken out in order to qualify for the protections of reconciliation.

The Senate may also amend the bill and the House would have to approve those changes, which could again break the delicate coalition of House GOP support.

2. The House walks away from the debate.

In theory, if the GOP votes necessary to pass the bill continue to be elusive, the House could just leave health care for another day — or another year. That would be a huge setback for President Donald Trump, who campaigned on a pledge to “repeal and replace” the health law, as well as for congressional Republicans, who have been promising to do the same since the bill became law in 2010.

But if the law truly implodes for 2018, meaning insurers drop out of so many areas that millions of people have no insurance options, it could trigger an entirely different health debate.

3. The House decides to switch gears to tax reform.

Health care is not the Republicans’ only high priority. So is an overhaul of the federal tax code.

But Republicans want to use the same budget reconciliation procedure to pass their tax plan. That’s a problem.

In order to make sweeping tax changes under expedited budget rules, the House and Senate would have to move on to a fiscal 2018 budget resolution, which would override the 2017 budget blueprint. But as soon as it does, the protections for the health bill would expire.

There is another option. Each budget resolution can allow one spending bill and one tax bill to be protected by reconciliation rules. So Congress could simply start the process over in a 2018 budget resolution that would allow it to move on tax reform and changes to the health law simultaneously.

4. Congress tries to overhaul health law incrementally.

The House could abandon the budget process and simply pass bills without regard to whether they have an effect on the budget. The first step, though, would likely be for the House to repeal the ACA wholesale — giving Republicans political cover. Then they could take up smaller pieces of legislation, such as a bill that would allow health insurance to be purchased across state lines, a favorite idea of Trump’s. Those bills, however, would require 60 votes in the Senate, which seems unlikely given Democratic opposition.

If the GOP efforts to bring wholesale change to the ACA are exhausted, though, it may be possible for some moderate Republicans to craft legislation with Democrats to fix some of the issues that both parties see in the law.

5. The Senate gets rid of the legislative filibuster.

The Senate earlier this year abolished the need for 60 votes to fill a Supreme Court seat, which got Trump’s nominee, Neil Gorsuch, approved. Trump has been calling for Republicans to also get rid of the filibuster for legislation. “Either elect more Republican Senators in 2018 or change the rules now to 51%,” he tweeted on Tuesday.

But the legislative filibuster is the last protection for a Senate minority party, and Republicans know they will someday be that minority again. Senate Majority Leader Mitch McConnell (R-Ky.) has said repeatedly he has no intention of taking this step, telling reporters Tuesday it “would fundamentally change the way the Senate has worked for a very long time.” And even if he changed his mind, he might have trouble persuading some of his Republican colleagues to go along.

–Julie Rovner, Kaiser Health News

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20 Responses for “Preexisting Condition: How Health Care Wrangle May Play Out Over Obamacare Repeal”

  1. Diana L says:

    The President promised that healthcare would be amazing, that pre existing conditions would be covered, that deductibles would be lower, that premiums would be lower. Why aren’t they waiting for a CBO score? It seems to me, they want a win, no matter what it does to us. The ACA was not perfect but it did improve healthcare. Why would they take us back? Members of congress have no idea what it costs or how many of us it will affect. This is a sad day for America. Party over Country AGAIN, and AGAIN and AGAIN.

  2. Anonymous says:

    It’s a shame that people are willing to pay such a high price for the dubious pleasure of their prejudices. There’s always a bill at the end of the meal, especially when we display such a pronounced propensity to eat our own.

  3. Fredrick says:

    Yes Healthcare is a disaster. Obama made it worse with a plan that passed only because he lied over and over again about it it’s benefits. This bill will not be much better. To think it will be is foolish. But when a family of 4 with a diabetic son making $85k a year, does not take vacations, lives in a small house, drives old vehicles can’t afford the premiums, and only thing covered is something catastrophic, there is an issue.

  4. Nancy N. says:

    Today, the GOP majority in the House voted to create conditions in our healthcare system that could literally jeopardize the lives of my daughter, my husband, and me.

    My daughter’s body, according to her rheumatologist, starting turning on her and trying to destroy her own joints shortly after her birth. At age seven, she developed an auto-immune skin condition that can progress to a version that can destroy the major organs in the cardio-pulmonary system. (Now, a week before her 14th birthday, she’s currently undergoing testing to see if she’s possibly developed that potentially lethal version of the disease.)

    At age 18, I had my first lupus symptom. I have literally been sick my entire adult life. I don’t know what it is like to have the unlimited options and horizons that health brings. My entire life has been built to accommodate the need to have insurance, freedom to schedule doctors appointments, and to accommodate my body’s limitations.

    This AHCA bill to repeal and “replace” the ACA law is targeted squarely at kicking people like my daughter and I out of the private insurance market. We are expensive to keep alive and insurance companies don’t see people…they see bottom lines that keep their shareholders happy. Equations of live people versus dead people don’t count on the stock market. Insurance company CEOs don’t get bonuses for how many lives they save. They get bonuses for how many dollars they save. Kicking people like my daughter and I out of private insurance is dollars saved for these companies.

    This bill is so bad that it will leave more people without meaningful insurance coverage than there were before the ACA law. Think about that – about how bad that was – and then multiply it by millions more people left without care. Any Congressperson who votes for this law is voting to kill people, because people WILL die when the ACA law is taken away from so many people. They died before it, and they will die again now without it. The GOP has been screaming about “death panels” for years…this Congress will be the real death panel if this bill becomes law.

    But if the GOP thinks they have all of the power on this issue they are mistaken.

    I will not stand by while a staff member of my elected representative in Washington tells an acquaintances of mine that the Representative only works for the voters of his party, not all residents of his district. I will not stand by while that Representative leads the Freedom Caucus in taking a stance that it is more important for billionaires to get a tax credit than for my daughter to receive life-saving care. I will not stand by while bus loads of GOP Representatives travel to the White House to be patted on the back by the President for their “success” in making progress towards taking healthcare away from people who need it the most.

    Ron DeSantis…you may think that you won today. But 2018 is coming. And I, and the people like me, will make sure that election day is your day of reckoning and that this vote of yours is seared in the memories of every voter in this district when they go to cast THEIR votes. We will not forget, and we will make sure that no one else does either.

    This is the turning point in the tide of power in Washington. This is the day, Ron DeSantis, that you will look back at and think…I wish I had done the right thing.

  5. MS Auggie says:

    I have only Medicaid , so I REALLY worry, WHAT cuts, they think they are going to make. In Bunnell, I saw a Dr, where I HAD to sit in my car- ALL weather, & get called in, by receptionist, along with almost everybody else. Waiting room was THAT small. See, you dont GET to choose a great Dr on Medicaid. You pick from the few they have to offer & if you cannot travel well…. you’re stuck with the few Locals,— Exactly WHY I PAY to see a decent MD, $85.00 each visit- HE CARES. For some things, certain emergencies- I CAN go to emergency clinics, God bless those!!!!!

  6. a tiny manatee says:

    Congrats trumpets, you got the healthcare you deserve. Enjoy that pre-existing condition clause and the lack of controls on medication costs, you’ve earned it!

  7. steadfast&loyal says:

    Providers are ditching oblama care faster than roaches when the lights go on. So let it run its course if they can’t get this passed. When people CANT get any coverage, or only a 10k premium with 10k deductible, they will get off their apathetic arses. Til then we watch this political nonsense continue. Once oblamacare goes south, the left will have no options but to repeal/replace.

  8. Mark101 says:

    All I want to hear from this presidents mouth is (1) “per-existing conditions will be covered (2) there is NO reduction in benefits for the over 65 crowd (3) for those over 65 healthcare is free since you paid your dues as hard working people. Now this would be a very very very good deal for the over 65 crowd. (4) Do not tax the middle class to death in covering the cost, find it somewhere else.

  9. Flatsflyer says:

    The new Bill has 1,900 pages, more than Obama Care. It was written in the backroom with no public input or hearings. Every major medical association has come out against it. the only people benefitting from it are the politicans by getting bribes, the insurance companies, the 1% who are getting tax breaks that will choke a horse. The Republicans have screwed the people again but that was by design as is usual with them. The people hurt the most are the GOP and Trump people, they hope all the poor die quickly.

  10. Geezer says:

    At least Barak Obama tried to give Americans universal healthcare,
    unlike the orange shit-stain who’s looting the White House today.

    Obama wanted to open up Medicare, and set up a single-payer system,
    but NO, the insurance companies have their puppets installed in congress,
    who didn’t like the effect Medicare would have on their gilded pockets.

    One thing about Trump: somehow behind the scenes, he arranged for
    almost half of the US to receive lobotomies “on the house,” and in
    total secrecy.

    Proof? He was elected.

  11. a tiny manatee says:

    Ladies and gentlemen, I present to you the typical boomer: it believes that it is entitled to free health care and pre-existing coverage care, just because it is over 65. Observe as this
    addled creature consistently chooses candidates based on racist and nationalistic rhetoric alone, and then is surprised when decisions are made against its own selfish interests. Behold as it goes extinct, much like the dodo, but thankfully clearing the path for a generation far less selfish and far more wise but nonetheless saddled with the asinine consequences of decisions made by old, selfish, and angry ghosts.

  12. Pogo says:

    @a tiny manatee

    By Traci Pedersen
    ~ 1 min read

    “Ageism is a form of discrimination toward an individual or group based on their age. The term often refers to the treatment of older people but is occasionally used to define prejudice against young people as well.

    The term ‘ageism’ was coined in 1969 by Robert Neil Butler, the first director of the National Institute on Aging and a Pulitzer Prize winning-author. He defined ageism as having three connected elements: prejudicial attitudes toward older people, old age and the aging process; discrimination against older people; and practices and policies that perpetuate stereotypes of older people.

    Some particularly persistent stereotypes toward older people include the following: being unable to contribute to society, having a poor memory, being slow and inactive, being out-of-date, and lacking knowledge of technology.

    Stereotypes against younger people may include thinking they are too young to contribute any wisdom or knowledge, believing that they cannot think for themselves, or that they will be unruly and misbehave…”

    May you live long enough to receive what you so generously give.

  13. Ws says:

    Obamacare is going down the tubes fast anyway so why is it that people don’t seem to understand that fact? It baffles me to hear all the complaints as if they think they will be able to keep there Obamacare when in fact that is not true. Obamacare is going away so please read and understand that! Healthcare should not be free for everyone. People who work have to contribute and pay for it. I am so tired of people somehow believing they should be entitled to get it for free. Why? Next thing will be people thinking they should get their houses for free. Geez.

  14. A tiny manatee says:

    I’d love to Pogo, assuming that there’s anything left once the boomers are through raping it for their own benefit.

  15. Geezer says:

    a tiny manatee:

    A note from a “Boomer.”
    This here boomer, has paid into Social Security via paycheck deductions for over thirty years.
    I never questioned this deduction, as I knew that I was BUYING a healthcare plan to cover me
    after retirement or in case of a debilitating illness.

    But I’d like to see a provision for an upstanding citizen like you to be able to opt-out of Social Security
    or any form of government subsidized healthcare. This way, if and when the day comes that you can’t
    work anymore – you can stand on a corner and beg for pocket change, and hope that there’s a free clinic
    that will give you state-of-the art care when you have an illness. You’ll be begging for sure, because your
    life savings and home will be gone to pay for your hangnails and chronic flatulence.

    And since you will have opted out (because of your righteous indignation)–you’ll just have to DIE and
    make room for younger and healthier subjects to take your place.

    You’re god-damned right I’m entitled. I effing paid for it. And if my country of birth decides to not
    honor contracts with its citizens, then this isn’t such a nice country now, is it.

    You have been indoctrinated into a cult-like mentality where you can free yourself eventually by
    engaging in critical thinking, and the avoidance of regurgitated right-wing, piffle-laced commentary.

    I look forward to that orange phallus-headed, orange comb-over, douche-nozzle “president”
    being impeached. Is he wearing a hen as a hat?

    Have a nice day tiny manatee, and watch for uncaring boaters who refer to your species as
    “speed bumps.” Surface, and get some sun, so your troglodytic thought processes may ebb away.

    Maybe it’s a lack of Vitamin “D.”

    Oh, and bless your heart.

  16. Mondexian Mama says:

    It is interesting to note a large number of hospitals are owned by the religious right. These are the kind people who turned away a woman bleeding to near death from faulty IUD because it served as birth control,these are the kind people who argued successfully that a fetus was not a person. Trump sold his soul to these religious extremists to get elected and in doing so he also threw away our chances of getting quality health care. The number of pre existing illnesses no longer to be covered is astounding,all stacked in favor of the industry of religion. So when you have a loved one rotting away on their death bed or a child being eaten alive by cancer,fear not,just pray and Jesus and the Donald will be there to help.

  17. Diana L says:

    I believe it is very sad that some people in our community find it necessary to throw around ugly names and disrespect each other. I, also, believe we all want affordable and excellent healthcare. Those two items might be a good place to start. It won’t be easy to solve any problems if we continue on the path we are going.

  18. Ws says:

    Hey Geezer you sound pretty mean. Geez.

  19. Lazaruis says:

    I agree with Diana L first statement.
    I hope the Senate kills this bill .
    If they take the time to actually read it I am sure they will not let it pass .
    For the HOUSE to pass it so they could say they got a win comes at a great loss to the American peoples.

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