A leaked draft of an outdated GOP plan to repeal the Affordable Care Act (ACA) indicates that congressional Republicans are in “total disarray” about how to dismantle President Obama’s signature health-care reform law.
At least some key details of the February 10 draft, which repeals the law’s Medicaid expansion without any replacement, contradict Republican operating procedures to unravel the ACA, also known as Obamacare, amid an escalating constituent backlash. Republicans in the U.S. House of Representatives are leading the initial charge as their counterparts in the U.S. Senate await a viable bill to consider.
House Majority Whip Steve Scalise (R-LA) told reporters Tuesday that the 106-page document is “no longer a viable draft that we’re working off of,” even as House Speaker Paul Ryan (R-WI) defended it. Despite the internal division, the draft indicates that for the GOP, all roads lead to restricting access to reproductive health care.
Section 111 of the House GOP’s draft devolves the ACA’s “essential health benefits,” a set of ten categories of health services that health plans in the individual and small group markets must cover, to the states by the end of 2019. Doing so effectively kills the federal requirement by letting states set their own standards, which could allow those states led by GOP-majority legislatures to cut off birth control coverage in plans sold within their borders.
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One day before Politico first published the draft, which many Republicans directly involved in the ACA repeal process reportedly had not seen, Rep. Michael Burgess (R-TX) told the audience at the Conservative Political Action Conference (CPAC) that Republicans would punt undermining essential health benefits to the U.S. Department of Health and Human Services (HHS). The benefits categories include pregnancy, maternity, and newborn care, as well as a wide range of preventive services, including contraceptives.
The requirement to cover contraceptives at no cost to the consumer falls under another section of the ACA: Section 2713’s Women’s Health Amendment. Under the Women’s Health Amendment, most private insurance plans, including employer plans, must include coverage of contraceptives without consumer cost-sharing. This provision is also known as the popular birth control benefit and includes other women’s preventive services as supported by the Health Resources and Services Administration, an arm of HHS.
Republicans in Congress and the administration have not hidden their disdain for no-copay contraceptives. HHS Secretary Tom Price believes there’s “not one” woman who can’t afford birth control. As anti-choice Republicans vow to get rid of the birth control benefit, either legislatively or through HHS action declassifying contraceptives as women’s preventive care, one possibility includes attacking the benefit under the Women’s Health Amendment. As Rewire‘s Jessica Mason Pieklo explained, agency-level action could occur through an HHS rule-making process or a long-awaited religious imposition executive order from the White House.
Debra Ness, president of the National Partnership for Women & Families, criticized Republicans for attacking essential health benefits, which she called “a groundbreaking advancement for women’s access to quality insurance coverage.”
“Under this proposal, women would no longer have the assurance that they could obtain or afford coverage that includes maternity care,” Ness said in an email. “And, it interferes in women’s ability to make health-care decisions by making abortion coverage inaccessible.”
Democrats on Capitol Hill eyed the GOP’s latest pivot with skepticism.
“It’s not at all surprising that Rep. Burgess and other Republicans would say one thing at CPAC and do another in their legislation,” a House Democratic aide familiar with the situation told Rewire. “If anything is clear at this point it is that there is no consensus in the GOP about how they should proceed. They are in total disarray.”
Democrats believe the draft has “changed considerably” since mid-February but haven’t seen updated versions, according to the aide. The core tenets of entrenched opposition to contraceptives and abortion access likely remain the same.
“We can see from this bill where House leadership’s priorities lie—in denying women access to quality, affordable health care, including the comprehensive reproductive health care and abortion services that are essential to their health, equity, and economic security,” the National Partnership’s Ness said.
Recycled anti-choice plans that GOP leaders have promised to deliver feature prominently in the draft. Within the first 30 pages alone, Republicans “defund” or strip Planned Parenthood of Medicaid reimbursements for one year and direct $285 million to community health centers that are not prepared to fill the resulting gap in care. A placeholder for “Hyde language to be included” would double down on the existing ban on federal funds for most abortion care.
House Republicans’ insistence on defunding Planned Parenthood could stall or sink the bill in the Senate. Mixed-choice Sen. Lisa Murkowski (R-AK) confirmed last week that she would not vote for an ACA repeal bill that targeted the health-care organization, according to an Alaska Dispatch News report. Should fellow Planned Parenthood ally Sen. Susan Collins (R-ME) defect, Vice President Mike Pence would have to cast a tie-breaking vote.
Others could bow to pressure from their constituents.
Angry crowds met their U.S. representatives and senators in their home districts during last week’s congressional recess. Many GOP lawmakers cancelled regularly scheduled town hall meetings or distanced themselves from the Trump administration’s agenda. Those who stubbornly repeated GOP talking points about Planned Parenthood fared worse. Rep. Marsha Blackburn (R-TN), who led a $1.59 million “witch hunt” into false allegations against the health-care organization, encountered shouts of “shame on you” and “lies.”
Back in Washington, Republicans continue to change direction, raising questions about how solid their draft was.
Republicans may have included the essential health benefits repeal in the draft in order to lower its Congressional Budget Office (CBO) score, or government price tag, according to a second House Democratic aide. The Hill in early February reported that Republicans have been working with the nonpartisan office on the cost of repealing the ACA.
Eliminating the essential benefits reduces the costs of health-care plans, in turn reducing the overall cost of the legislation. But that plan may have backfired on Republicans after the CBO reportedly came back with an “atrocious” number, the aide said.
The Democratic aide did not know which iteration of Republican drafts the CBO scored.
Republicans delayed their goal to mark up the reconciliation bill on March 1, the aide said. Of the two committees of jurisdiction, the House Energy and Commerce Committee, chaired by Rep. Greg Walden (R-OR), will still likely move first; some Republicans are insisting there will be a markup on repeal legislation next week.
The tax-writing House Committee on Ways and Means, chaired by Rep. Kevin Brady (R-TX), will also have to hold a markup.
The aide underscored that the essential health benefits issue is tied to another key ACA provision—the “hot, hot button issue” requiring insurance companies to cover people with pre-existing conditions.
Republicans may keep that fan-favorite provision. Walden in mid-February introduced legislation, the Pre-Existing Conditions Protection Act (HR 1121), “to reaffirm guaranteed health care access, ensure that enrollees cannot have benefits excluded from a plan due to a pre-existing condition, and that patients will not pay more based on their health care status.”
If Republicans are forced to maintain coverage for pre-existing conditions, they would all but certainly get rid of essential health benefits, the aide said. In other words, insurers would be required to sell plans to people with pre-existing conditions, but they wouldn’t have to offer the coverage they used to under the ACA or face penalties.