Questions About Protections for the Sick Divide Republicans on ACA Repeal

House Republicans left for their spring recess without passing an ACA repeal largely because they remain divided on several thorny health policy issues, with little sign anything will change in the near future.

Hardline conservatives want to give states the option to waive the Affordable Care Act’s protections for people with pre-existing health conditions, while more moderate Republicans are reluctant to sign onto those changes without a system in place to ensure people with a history of illness can get insurance coverage on the individual market. Members agreed before leaving for recess to add $15 billion to their repeal bill to underwrite coverage for people with serious health conditions for a few years, but it might not be enough to convince many in the party to sign onto more changes to the legislation.

There are a number of policy details Republicans must iron out, Rep. Greg Walden (R-Ore), chairman of the House Energy and Commerce Committee, told me recently, including how waivers are granted, which parts of the ACA can be done away with, how to ensure that people with chronic health conditions can obtain coverage and whether the changes are allowed under Senate rules.

Republican leaders have vowed to maintain protections for people with expensive health conditions even as they repeal the health law, Walden said. The short-term federal risk-sharing program that conservatives and the White House have proposed may not be enough to guarantee coverage for everyone, he said.

“I'm not going to go to a place that removes pre-existing condition protections, period,” Walden said.

Hardline conservatives, meanwhile, are insisting that any repeal bill include provisions lifting the ACA's pricing and plan design requirements or allow states the option to decide if plans sold within their borders must follow these rules. Members of the House Freedom Caucus, a conservative faction in the House, are now trying to convince the rest of the GOP conference that this change can reduce insurance premiums for plans sold on the individual market without compromising protections for the sick, if it's coupled with funding for high-risk insurance pools.

The White House effort included two visits by Vice President Mike Pence to Capitol Hill this week to try to broker a deal between conservative and moderate Republicans to pass a modified version of the American Health Care Act, the bill championed by House Speaker Paul Ryan (R-Wis.) and President Donald Trump. The AHCA failed to go up for a vote before the full House in late March, after losing support from both moderate and conservative Republicans.

Pence offered members of the House Freedom Caucus an amendment that would allow states to request from the federal government waivers of the ACA's essential health benefits rules (the 10 categories of health services health plans sold on insurance exchanges must include) as well as community rating requirements, which prohibit insurers from pricing health plans individually, instead tying prices to age and location of the beneficiary, among other factors.

However, community rating requirements are at the heart of the health law's protections for people with serious health conditions, Rep. Tim Murphy (R-Pa.), a member of the moderate Tuesday Group, told reporters recently. If insurers can price plans individually, the sickest could be priced out of the market.

Rep. Patrick McHenry (R-N.C.), the House GOP's chief deputy whip, told reporters these protections are essential for him to support any repeal bill. Before the ACA, people with serious health conditions buying plans on the individual health insurance market often paid extremely high premiums or were simply denied coverage, he said.

“I look at this, understand the impact of regulation, but also the impact of really bad practices in the insurance marketplace prior to the ACA passing,” McHenry said.

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