More than a month after Republicans decided to not vote on a budget resolution that would gut the Affordable Care Act, a revised version of that resolution finally came to the House floor for a vote this afternoon amid concerns that there is no estimate yet on what these changes will cost and how they will affect millions of Americans with pre-existing conditions.
The House passed the bill by a vote of 217 to 213, with only 20 Republicans breaking rank to come out against the American Health Care Act. No Democrats supported the AHCA, which now goes on to the Senate. Because it is a budget resolution — as opposed to a traditional piece of legislation — it will only need a simple majority in that chamber, as opposed to the usual 60 votes.
The 20 Republicans who voted against the bill were Andy Biggs (AZ), Mike Coffman (CO), Barbara Comstock (VA), Ryan Costello (PA), Charles Dent (PA), Daniel Donovan (NY), Brian Fitzpatrick (PA), Jaime Herrera Beutler (WA), Will Hurd (TX), Walter Jones (NC), David Joyce (OH), John Katko (NY), Leonard Lance (NJ), Frank LoBiondo (NJ), Thomas Massie (KY), Pat Meehan (PA), David Reichert (WA), Ileana Ros-Lehtinen (FL), Chris Smith (NJ), and Michael Turner (OH).
Among the key points of what’s in the AHCA:
• Nullifies the individual mandate — the requirement that most people have some sort of health insurance.
• Nullifies the employer mandate — the requirement that larger employers provide qualifying coverage to full-time workers.
• Allows individual states to opt out of certain requirements of the Affordable Care Act — like restrictions on charging individuals more for insurance if they have pre-existing conditions, or mandates that insurance providers in that state must cover the ten “essential” health benefits as defined by the ACA.
• Make over-the-counter medications eligible for purchase through tax-advantaged savings plans like flexible spending accounts and health savings accounts.
• Remove the limits on annual contributions to flexible spending accounts.
• Provide a refundable tax credit — based on age and income — of between $2,000 to $4,000 to individuals (capped at a total of $14,000 per family) who do not have access to government health insurance programs or an offer from any employer; are a citizen, national or qualified alien of the United States (and are not incarcerated) who purchase qualifying insurance on their own. Currently, veterans who are eligible for benefits through the Department of Veteran Affairs would not be eligible for these tax credits, even if they don’t want or have VA benefits.
• Increase the limit on Health Savings Accounts so that they are equal to the sum of the annual deductible and out-of-pocket expenses permitted under a high deductible health plan.
• Repeals the 10% tax on indoor tanning services.
• Allows Medicaid expansion to continue to enroll people until January 2020, at which point there will be a “freeze.”
The latest version of the AHCA — only made public late last night — has not yet been scored by the nonpartisan Congressional Budget Office, which is generally required to chime in on budget resolutions before they are passed. Previous CBO scoring of this resolution estimated that it would lead to 52 million additional Americans going without health insurance by 2026, while only cutting about $150 billion from the federal deficit.
Critics of the resolution expect that the amendments allowing for states to opt out of ACA requirements will likely increase the predicted number of uninsured and decrease the estimated deficit reduction.
While neither the resolution nor its amendments went through the traditional committee process, allowing for hearings and debates, Democrats were given a brief opportunity to once again voice their concerns about the AHCA, repeatedly attempting to drive home the fact that Americans with pre-existing conditions may be priced out of coverage if states opt out of requirements that currently limit insurers’ ability to charge higher rates to people with costlier medical issues, or who have had lapses in their coverage.
According to the nonpartisan Kaiser Family Foundation, some 27% of adults under the age of 65 have at least one condition that would have barred them from getting health insurance on their own without Obamacare. It’s not yet known how many states will choose to opt out of this requirement.
Republicans repeatedly responded to these concerns by pointing out that the law still explicitly bars insurance companies from denying coverage to people with pre-existing conditions, and that states that choose to opt out of these restrictions must create either so-called “high-risk pools” or reinsurance programs to provide coverage.
However, that same Kaiser Foundation report noted that 35 states had such programs before the Affordable Care Act, but that only a small fraction of eligible people in those states were actually enrolled, and almost all of these programs had exclusions or restrictions on pre-existing conditions. A high-risk pool that does not include such restrictions may attract a larger number of Americans.
As part of the ramp-up of the Affordable Care Act, the federal government created the Pre-existing Condition Insurance Program — a nationwide high-risk pool. Enrollment in PCIP peaked at only around 115,000 individuals at an annual cost of around $2 billion per year.
The AHCA has set aside a total of $138 billion over ten years to support such pools, which Republicans contend will be sufficient to provide coverage, but which critics believe will fall far short. One estimate, from the Center for American Progress, estimates that the real ten-year cost for providing adequate coverage could be more than double that amount. A 2008 estimate from the nonpartisan Tax Policy Center calculated that a nationwide high-risk pool would require more than $1 trillion over ten years.
Ultimately, enrollment in any high-risk pools will depend on how many states opt out the Affordable Care Act requirements, how much individuals in those states are charged, and what sorts of coverage are provided by those programs.
The AHCA now passes on to the Senate, where it only needs a simple majority to pass. However, some Republican Senators have already voiced concerns, if not outright opposition, to the bill. Republicans only hold a two-vote majority in the Senate, so it would effectively need a party-line vote to pass the resolution.
As some moderate Republican House members noted during today’s debate, the AHCA will continue to be modified by the Senate, hopefully addressing problems like a loophole that would shut out millions of veterans from obtaining tax credits if they are eligible for benefits from the Department of Veteran Affairs, even if they don’t currently seek healthcare through the VA.
If the Senate passes an altered version of the resolution, it would need to go back to the House for reconciliation.
Our colleagues at Consumers Union, who had called for Congress to reject the AHCA expressed their disappointment about today’s vote.
“The House of Representatives today failed their constituents and the American health system by passing the American Health Care Act,” said Betsy Imholz of CU. “In a field where ‘do no harm’ is the standard, this bill does nothing but harm American families. Taking insurance away from 24 million people, devastating Medicaid, rolling back protections for preexisting conditions and older consumers, increasing out-of-pocket costs, encouraging junk insurance plans without any meaningful coverage, ​and even allowing the elimination of out-of-pocket cost caps and reinstating lifetime limits for the nearly half of all Americans who get their coverage through their employers — these are the real consequences of the AHCA. Each iteration has only made this bad bill worse.”

Editor's Note: This article originally appeared on Consumerist.