Healthcare providers knew it was coming, but the House of Representatives vote on Thursday to approve the amended American Health Care Act was disappointing nonetheless.
The House voted 217-213 in favor of passing the Republican-sponsored plan that would unravel key provisions of the Affordable Care Act, President Barack Obama’s signature legislation. The House erupted in song after the final vote, with Democrats singing the lyrics “nah nah hah. hey hey goodbye.” Democrats reportedly chanted the song as a message to Republicans that though they may have won the first round, the bill won’t pass the Senate.
Pelosi and Hoyer claim that Dems' singing "hey hey goodbye" 👋 to Republicans was spontaneous. "Just burst into song," Pelosi said, grinning.— Dan Diamond (@ddiamond) May 4, 2017
But provider groups, including the American Hospital Association, American Nurses Association and the Federation of American Hospitals, said they were deeply disappointed in the passage of the bill because it jeopardizes health coverage for millions of Americans. They are holding out hope that House Democrats are right and the Senate won’t allow the current bill to head to President Donald Trump’s desk.
“As passed by the House of Representatives, the AHCA fails to protect the health coverage and access to care for so many Americans. It also makes it more difficult for hospitals to deliver the care we all rely on,” Chip Kahn, president and CEO of the Federation of American Hospitals, said in an emailed statement to FierceHealthcare shortly after the vote.
Kahn said the vote was “disappointing, but not surprising” considering Republicans have set their sights on repealing and replacing the ACA since its passage in 2010.
Jeffrey Hulburt, president and CEO of Beth Israel Deaconess Care Organization (BIDCO), a value-based physician and hospital network and an accountable care organization (ACO) in Massachusetts, said in a statement that the bill appears to shift the cost burden to people with pre-existing conditions. “House Republicans want to replace the protections Obamacare provides for those with pre-existing conditions with federally funded, high-risk pools; however, it is unclear whether the amount allocated is enough to provide affordable access to care to everyone who needs it.”
Perhaps the most passionate response came from Jim Mangia, president and CEO of St. John's Well Child and Family Center, an independent 501(c)(3) community health center based in Los Angeles, who called Thursday's vote in an emailed statement, "an act of attempted homicide against the American people, in particular the most vulnerable among us. Should this pass the Senate, there is no doubt that many people with pre-existing conditions, low-income families on Medicaid, and many more will die as a result of this disgraceful and cowardly act by our elected officials."
The passage of the AHCA by Congress was an act of attempted homicide against the American people, in particular the most vulnerable among us— St. Johns Well Child (@Wellchildorg) May 4, 2017
The bill’s rocky road
The Republican’s replacement plan for the ACA has had a bumpy road from the get-go. House Speaker Paul Ryan pulled it shortly before the House was supposed to vote on the original version in March because it didn’t have enough votes. Since then Republicans have been making changes to the legislation to sway reluctant moderates and conservatives.
But those last-minute changes—which allow states to apply for waivers to opt out of certain ACA provisions and provides an additional $8 billion over a five-year period to help people with preexisting conditions who live in states that opt for those waivers—may not prevent millions of Americans from losing their health insurance.
The Congressional Budget Office estimated that under the original version of the AHCA, 24 million people could lose health insurance by 2026 but the legislation would shrink the federal deficit by $337 billion from 2017 to 2026. But the CBO didn't have time to analyze the current bill before Thursday’s vote so it’s unclear just how many people may lose their coverage under the amended plan. And that's what worries healthcare providers the most.
Amendments don’t squelch fears
The American Medical Association said that although the current healthcare insurance system needs improvements, the House bill means patients with “pre-existing health conditions face the possibility of going back to the time when insurers could charge them premiums that made access to coverage out of the question.” The AMA issued a statement, urging the White House administration and the Senate to work with physician, patient, hospital and other provider groups to come up with a bipartisan solution so that all Americans can have access to affordable and meaningful coverage.
Rick Pollack, president and CEO of the American Hospital Association, expressed similar concerns. He said the amended proposal eliminates essential protections for older and sicker patients, including those with pre-existing conditions, such as cancer patients and the chronically ill. “It does little to help the 24 million Americans who would be left without coverage following repeal and makes deep cuts to Medicaid, which provides essential services for the disabled, poor and elderly people in this country,” he said in a statement.
Hospital payer-mix questions
The reactions by the provider groups didn’t come as a surprise to healthcare practice lawyers. The health policy bill effects the entire industry and for healthcare organization executives it will impact their payer mix, noted Lowell Brown, partner and national leader of the healthcare practice group for Arent Fox.
“If you are a hospital you are mainly concerned with whether people are going to have coverage and what your payer mix is going to look like. It may sound mercenary but it’s not. It’s just a matter of staying in business and the mix can vary from hospital to hospital and county to county,” he told FierceHealthcare.
One of the biggest impacts of the ACA was the provision to expand Medicaid, Brown said, and the biggest impact of the Republican replacement plan (as it stands now) is what will happen to Medicaid now.
And that is one of the many unanswered questions, noted Beth Halpern, a health law partner in Hogan Lovells’ District of Columbia office. Without a concrete analysis of the changes, she said it’s unclear how many states will seek waivers or how many will use high-risk pools, how many will lose insurance and, if they buy insurance, how much it will cost them. There is little assurances so far that this will protect more people, she said.
Next steps for hospitals
Halpern urges stakeholders concerned about the bill to contact their Senators with specifics on what they believe needs to be fixed and also urge them to make sure the CBO can score the latest bill before they vote.
As for the future, Brown said that the latest version of the AHCA provides an even greater need for hospitals to integrate care. The ACA pushed physicians, long-term care providers and hospitals to integrate and move to electronic health records. “These were already in motion and will continue. More than ever providers need to focus on those things as we move into the new world of healthcare. The bill is all about how it’s paid. While that’s uncertain, if your delivery system is fragmented, that will be much harder to deal with these challenges,” he said.
Hulbert said organizations and lawmakers should focus on on innovative models and approaches that will reduce healthcare costs. “We know we can drive down costs and still achieve high-quality health outcomes when providers and hospitals form partnerships to coordinate all aspects of patient care and share financial risk. We've seen it work first-hand,” he said, adding that CMS statistics show that BIDCO achieved $55 million in savings while improving care quality for Medicare patients.