March 23, 2017

House Republican efforts aimed at securing passage of their Affordable Care Act (ACA) repeal and replacement measure reached a fever pitch this week as party leaders sought to bring their legislation to the floor on Thursday, March 23, the seven-year anniversary of the enactment of President Obama’s signature healthcare reform law. As of Thursday afternoon, the GOP leadership in the House have decided not to bring the bill (HR 1628) to a vote today. They are meeting Thursday night to consider options.

With every Democrat poised to oppose the legislation, at issue for Republican leaders is the continued holdout of the 30-member House Freedom Caucus. The group, comprised of the most conservative members of Congress, has repeatedly insisted that the bill include provisions that would limit the “essential benefits” mandate of the ACA, which requires insurers to provide coverage for 10 categories of healthcare services. Conservatives are also pushing for changes in requirements that insurers cover people with pre-existing conditions.

To win over Freedom Caucus members, President Trump and other administration officials have been actively discussing with the group several potential last-minute revisions to the legislation. The negotiations dragged late into Wednesday night and continued at the White House on Thursday. GOP leaders risk losing the support of more moderate Republicans if they ultimately agree to changes that would push the bill too far to the right, setting up another potentially untenable scenario for House Speaker Paul Ryan (R-WI) and members of his leadership team.

The pending House floor vote was preceded by earlier action in the House Rules Committee. On Wednesday, a new version of HR 1628 was introduced in the committee and included language allowing states to choose either a Medicaid block grant or a per-capita cap on Medicaid payments, as well as a provision giving states the option to require work for certain individuals as a condition of receiving program benefits. In addition to being able to modify the underlying legislation, the panel sets the rules for full House debate, including which amendments will be allowed on the floor. As of this writing, the panel has not cleared the bill.

As the Rules Committee hearing commenced, CSAC sent a California county association letter in opposition to HR 1628. Signed by the associations representing human services, public hospitals, behavioral health, public health and the County Medical Services Program serving rural counties, the correspondence noted that the legislation would shift billions of dollars in costs to counties and reverse the significant progress California has made in providing health care coverage to millions of its residents.

The letter highlighted the bill’s proposed elimination of the enhanced federal Medicaid match, which lead to 3.7 million new individuals being covered under the Medi-Cal expansion. Additionally, the multi-organization letter cited the Congressional Budget Office’s projection that the federal contribution to Medicaid would be cut by 25 percent, shifting $880 billion in costs to states over ten years.

On a related matter, California’s Department of Health Care Services (DHCS) released a sobering analysis of the bill’s fiscal impact on the state, calling it a “massive and significant fiscal shift from the federal government to states.” DCHS estimates that the overall cost shirt to the state would total $6 billion in 2020, growing to $24.3 billion by 2027 – nearly three-quarters of that cost would need to be backfilled by the General Fund.