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Health Providers Denounce G.O.P. Bill as House Panels Get to Work Health Groups Denounce G.O.P. Bill as Its Backers Scramble
(about 5 hours later)
WASHINGTON — Two key House committees began formally drafting a repeal of the Affordable Care Act on Wednesday morning, even as the nation’s largest doctors’ group and a coalition of hospitals came out strongly against the Republican plan for replacing the law. WASHINGTON — Influential groups representing hospitals and nurses came out on Wednesday against a Republican bill to repeal and replace the Affordable Care Act, joining doctors and the retirees’ lobby to warn that it would lead to a rise in the uninsured.
Leaders of the committees — Ways and Means, and Energy and Commerce — portrayed the replacement bill in their opening statements as one that would rescue Americans from health coverage that had grown far too expensive and limited, painting a dire portrait of the nation’s health care system under the signature domestic achievement of President Barack Obama. But Democrats immediately began building their case against the legislation, emphasizing its elimination of taxes on businesses and high earners that have financed the Affordable Care Act. In a letter to lawmakers, major hospital groups wrote, “As organizations that take care of every individual who walks through our doors, both due to our mission and our obligations under federal law, we are committed to ensuring health care coverage is available and affordable for all.”
“This bill suffers from an identity crisis,” said Representative Richard Neal of Massachusetts, the top Democrat on the Ways and Means Committee. “Is this health care, or is this a tax-cut bill?” The groups, including the American Hospital Association, the Association of American Medical Colleges, the Catholic Health Association of the United States and the Children’s Hospital Association, said they could not support the bill “as currently written.”
Since congressional Republicans released the repeal-and-replace plan on Monday, a stream of medical and health advocacy groups, and AARP, have come out against it. Supporters of the bill so far are largely limited to those who would most directly benefit from its passage — groups that represent industries and individuals whose taxes would be cut, including the United States Chamber of Commerce and Americans for Tax Reform, a conservative anti-tax group. The hospitals and the American Nurses Association joined the American Medical Association and AARP, which rejected the bill on Tuesday.
On Wednesday afternoon, all major hospital groups, including the American Hospital Association, the Association of American Medical Colleges, the Catholic Health Association of the United States and the Children’s Hospital Association, came out against the Republican bill. “As organizations that take care of every individual who walks through our doors, both due to our mission and our obligations under federal law, we are committed to ensuring health care coverage is available and affordable for all,” they wrote. “As a result, we cannot support the American Health Care Act as currently written.” House Republicans have been left scrambling to marshal support from businesses and other interests that stand to benefit from lower taxes if the bill passes. Insurers are on the fence, and other powerful forces like pharmaceutical companies remain largely on the sidelines.
The American Medical Association, which has nearly 235,000 members and calls itself “the voice of the medical profession,” sent a letter to leaders of the two committees on Tuesday saying it could not support the Republican bill “because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.” In particular, the group came out against a plan to replace the sliding, income-based premium tax credits provided under the Affordable Care Act with fixed credits based on age. The current system, it said, “provides the greatest chance that those of the least means are able to purchase coverage.” Squeezed between wary health care providers and angry conservatives who believe that the bill leaves too much of the Affordable Care Act in place, the Republican leadership and President Trump appear to be facing an uphill climb.
America’s Essential Hospitals, which represents public and other hospitals whose patients are disproportionately poor, also criticized the Republican bill on Tuesday, saying its phaseout of the Medicaid expansion and its plan to change Medicaid financing to a fixed amount of money for each person in the program would harm its members and their patients. But the White House appears increasingly confident about the prospects for a health care overhaul to pass in the House. In a meeting with conservative leaders in the Oval Office on Wednesday, Mr. Trump said he anticipated the most trouble in the Senate, where moderate and conservative lawmakers are opposing the plan for different reasons. He said he was prepared to pressure holdout senators by holding the kind of stadium-style rallies he led during his presidential campaign.
Republicans have pressed forward, against the opposition not only of health care providers but their own conservative flank, which maintains that the bill leaves too much of the Affordable Care Act’s regulatory mandates in place. House Speaker Paul D. Ryan said Republicans were “going through the inevitable growing pains of being an opposition party to becoming a governing party.”
Mr. Neal and other Democrats called Republicans irresponsible for moving ahead with consideration of the legislation before receiving estimates of how much it would cost, and how many people would lose coverage, from the Congressional Budget Office, the official scorekeeper on Capitol Hill. “It’s a new system for people,” he added. “But it’s all the more reason why we have to do what we said we would do and deliver for the American people, and govern and use our principles.”
As morning turned to afternoon, Republicans sought to keep the sessions focused on the idea that the legislation was a desperately needed solution to, as Representative Greg Walden of Oregon, chairman of the Energy and Commerce Committee, put it, “a government-run system that is in collapse.” The array of groups taking strong positions against the bill is evidence that its potential consequences extend far beyond health insurance coverage, to much of the nation’s economy.
Representative Michael Burgess, Republican of Texas, described the Affordable Care Act as “a failed political and social experiment that ignored the will of people across the country.” The opposition is also a powerful reminder of how many past efforts to overhaul the American health care system failed because of resistance by major interest groups. Winning the support of the health care and insurance industries allowed the Obama administration in 2010 to push through the most significant health care legislation since President Lyndon B. Johnson’s Great Society.
But Democrats worked feverishly to portray the Republican bill as a reverse Robin Hood scheme that would devastate lower-income families while benefiting the rich. Representative Frank Pallone Jr. of New Jersey, the senior Democrat on the Energy and Commerce Committee, said the bill would produce “a giant transfer of wealth, taking from hard-working families and giving to the rich.” Moreover, he said, “billionaires will benefit, while Republicans dump huge out-of-pocket costs on working families.” Within a few months after President Barack Obama took office in 2009, his administration had lined up support from health care providers, insurers, consumers and pharmaceutical makers by offering a grand bargain: The health bill would include a requirement that most Americans have health insurance, providing millions of new customers through the law’s often substantial premium subsidies and its option for states to expand Medicaid. In exchange, hospitals would have to accept spending cuts and the health care industry would have to accept new taxes to pay for the legislation.
The Republican bill would roll back several tax increases imposed by the Affordable Care Act to pay for it, including a surtax on investment gains, a tax on medical devices and a tax on tanning salons. It would also delay a tax on high-cost, generous insurance plans that was intended to discourage overuse of the health care system. The Obama White House dedicated enormous effort to win pledges of support before Democrats even put out a bill — an effort not replicated by the Trump White House or Republican leaders in Congress.
But Democrats focused heavily on a provision in the bill that would give a new tax break to health insurance companies, allowing them to take tax deductions for executive compensation exceeding $500,000 a year. The Affordable Care Act barred deductions for salary and other remuneration over that amount. But the Affordable Care Act also created an array of taxes that the Republicans now hope to wipe away, helping them win the support of groups like the United States Chamber of Commerce and Americans for Tax Reform, led by the anti-tax activist Grover Norquist.
When Congress was writing that law in 2009 and 2010, Democrats harshly criticized insurance companies, their profits, and salaries paid to insurance executives. The congressional Joint Committee on Taxation issued estimates this week showing how much revenue the government could lose starting in 2018 under the Republican bill, which the party has called the American Health Care Act, as a result of repealing taxes on drug makers (nearly $25 billion over 10 years), insurers (nearly $145 billion), makers of medical devices (nearly $20 billion), and high-income households (more than $270 billion from taxes on earned income and investment income).
Mr. Obama said back then that insurance companies “pad their profits” while canceling coverage for the sick. Another provision of the health care law, in effect, capped insurers’ profits on Affordable Care Act business, requiring them to pay out a certain percentage of every premium dollar on medical claims and activities that improve the quality of care. “The American Health Care Act repeals the medical device tax, which will result in greater investments in medical cures, lower health care costs and more high-tech manufacturing jobs in communities across the United States,” trumpeted the Medical Device Manufacturers Association.
Lifting the cap on the compensation that can be deducted will cost approximately $400 million over a decade, according to an estimate from the Joint Committee on Taxation. Representative Brian Higgins, Democrat of New York, called the provision “morally reprehensible.” The extent to which these groups mobilize on behalf of the Republican bill may help determine whether it succeeds.
At noon, after 90 minutes of opening statements and parliamentary skirmishes, Democrats on the Energy and Commerce Committee insisted on a reading of the Republicans’ repeal bill. Committee clerks began reading the full text of the legislation, including an increase in federal funds for community health centers and a one-year ban on Medicaid payments to Planned Parenthood clinics. For now, the supporters of the House bill seem badly outgunned by opponents. On Wednesday, as two congressional committees took up the Republican repeal-and-replace bill, the American Nurses Association and a coalition of hospital groups came out against the proposal.
House rules and precedents generally require that a measure and proposed amendments be read in full. This reading is usually waived by unanimous agreement, but on Wednesday, Democrats on the Energy and Commerce Committee were in no mood to go along. They complained that the Republicans were rushing to approve the bill without following customary procedures. The A.M.A., which has nearly 235,000 members and calls itself the voice of the medical profession, sent a letter to leaders of the two committees on Tuesday saying it could not support the Republican bill “because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.”
Before the committee meetings got underway, Republican leaders emphasized that they expect an assessment from the Congressional Budget Office on the bill’s overall cost and impact on insurance before the House votes on the measure. Mr. Walden pointed out that the C.B.O. would have to change its conclusions to accommodate any amendments to the bill anyway. He said he “would almost guarantee” a score before the full vote. In particular, the group said it opposed a plan to replace the sliding, income-based premium tax credits provided under the Affordable Care Act with fixed credits based on age. The current system, it said, “provides the greatest chance that those of the least means are able to purchase coverage.”
The C.B.O.’s final grade is vital, not only because of its political weight but because Republicans are operating under special budgetary rules to protect the health legislation from a filibuster in the Senate. In order for it to pass the Senate with 51 votes — not the 60 needed to overcome a filibuster — the measure must save the government at least $1 billion over 10 years. If it costs the government money, Democratic opponents will easily be able to block it. America’s Health Insurance Plans, the health insurance lobby, released its own lengthy statement on Wednesday. In a letter to the leaders of the House committees that drafted the bill, Marilyn B. Tavenner, the group’s chief executive, warned Republican leaders that their plans to change Medicaid financing, among other things, could harm coverage and care.
But at this point, no one knows the legislation’s cost. While many insurers have lost money in the Affordable Care Act’s private insurance marketplaces, they have generally profited from the expansion of Medicaid, which would effectively be phased out under the Republican plan.
Mr. Walden dismissed criticism that Republicans were rushing their bill through. “As a core principle, we believe that Medicaid funding should be adequate to meet the health care needs of beneficiaries,” Ms. Tavenner wrote. “Medicaid health plans are at the forefront of providing coverage for and access to behavioral health services and treatment for opioid use disorders, and insufficient funding could jeopardize the progress being made on these important public health fronts.”
“It’s kind of funny,” he said. “In the first couple of months we were accused of moving too slowly and not having a plan. We’re doing this step-by-step, major process.” A day earlier, AARP — the association of middle-aged and older Americans that is another crucial supporter of the Affordable Care Act — had declared its opposition to the bill and had even started running an ad against it. In a letter to Congress, the group said the bill would increase health costs for people ages 50 to 64, could lead to cuts in Medicaid coverage of long-term care and would allow insurers to charge older people five times as much as younger ones.
House Republicans seemed optimistic they could overcome their disagreements. The hardening resistance complicated the case for the Republicans as they moved their bill forward on Wednesday.
“How can any Republican go home and say they voted against repeal and replace?” said Representative Chris Collins of New York, a member of the Energy and Commerce Committee. “I respect those organizations and their views,” said Representative Larry Bucshon, an Indiana Republican and a heart surgeon who conceded that criticism of the bill from doctors and hospitals could make it more difficult to sell the measure to the public. “Their voice is an important voice in health care.”
But, he noted, those groups supported the health care law in 2010.
“Hospitals have done quite well under the Affordable Care Act, but my constituents have not,” he said. “Their premiums are going up. Their deductibles are high.”
Across the rotunda, Republican senators were less enthusiastic.
Senator Shelley Moore Capito, Republican of West Virginia, said she was not certain that a delay in the rollback of Medicaid coverage was “enough for me.” Senator Lisa Murkowski, Republican of Alaska, expressed alarm that the bill’s tax credits would not account for higher premium costs in insurance markets like hers, a largely rural state with little competition. Senator Marco Rubio, Republican of Florida, said he did not want states that took the Medicaid expansion to “get a benefit” that the states that rejected the program did not.
Senator Susan Collins, Republican of Maine, said she was unhappy that the bill removed money for Planned Parenthood.
There was also a creeping concern about how quickly the bill was moving. Senator Mitch McConnell of Kentucky, the Republican leader, essentially promised to move the bill to the Senate floor without the hearings and other processes that are normal for such a far-reaching piece of legislation. He had promised when Republicans took the majority that they would honor normal Senate processes and traditions.
“I think if that’s the approach they take,” Mr. Rubio said, “they won’t have the votes in the Senate.”