‘Skinny repeal’ fails, next steps uncertain

Originally published on July 28, 2017 by healio.com. Written by Alaina Tedesco

Twenty hours of tense debate among the U.S. senators ended with the rejection of the “skinny repeal” bill—a major setback to President Donald J. Trump and the Republican Party’s plan to repeal and replace the Affordable Care Act.

Sens. John McCain, R-Ariz., Lisa Murkowski, R-Alaska, and Susan Collins, R-Maine, sided with Democrats to oppose the legislation, which failed by a vote to 49 to 51.

After the vote, Senate Majority Leader Mitch McConnell, R-Ky., expressed his disappointment in the GOP’s failure to deliver on its longstanding campaign pledge.

“It’s time to move on,” he said.

Healio Internal Medicine spoke with health care policy analysts about the next steps for health care legislation and what clinicians should be aware of moving forward.

“It remains unclear what will happen next,” Pari Mody, associate of Arnold & Porter Kaye Scholer LLP, said in an interview. “I expect that congressional Republicans will continue messaging the need to repeal and replace the ACA, though after the grueling work in the House and Senate over the past several months, it will be challenging to get leadership to take health care reform back up. In the nearer term, we could see bipartisan efforts to stabilize the markets, as Senate Health, Education, Labor, and Pensions (HELP) Committee Chairman Lamar Alexander, R-Tenn., has indicated interest in doing so.”

“First indications suggest that the administration is not planning on changing course, even though ACA repeal is less likely in the near-term,” she added.

Soon after the vote, Trump criticized Democrats and the three Republican senators who voted against the repeal and reiterated his call to “let Obamacare implode, then deal,” according to Mody.

“If the administration chooses to go this path, they certainly could,” Mody said. “Options include ending the cost-sharing subsidy payments, cutting off funding for ACA enrollment and education activities, suspending enforcement of the individual and employer mandates, as well as granting state waivers to avoid certain ACA requirements.”

Caitlin McCormick-Brault, associate director of the Center for Health Law and Policy Innovation of Harvard Law School, suggested that “the appetite for continued health care debate is rather low at this point given what both chambers have been through in this round.”

“During the marathon debate in the Senate, both Republicans and Democrats expressed an interest in having bipartisan discussion about health care,” she said in an interview. “The reality, though, is that they would still need to get the necessary votes to move anything forward, and that is going to continue to be very challenging. Realistically, I suspect Republicans will be very anxious to change the conversation and turn to another topic where they believe they can get a win, for the administration’s credibility and their own.”

Whether the ACA regains stability or begins to fall apart in the coming months will be determined by two critical questions, both of which depend on what constitutes as the president leaving the ACA “alone,” McCormick-Brault said.

“First, the ACA needs the administration to continue funding the cost-sharing reduction subsidies for insurer selling plans in the state marketplaces,” she said. “If the president declines to continue these payments, we will see premiums go up and many insurers will pull out from the marketplaces. Second, there is a robust system of regulations that implemented the ACA and fleshed out its consumer protections. If President Trump begins to proactively roll back these regulations, it would significantly undercut the ACA.”

In response to the Senate vote on the “skinny repeal,” the AMA and ACP issued separate statements urging Congress to start a bipartisan effort to tackle the inadequacies in the ACA.

“While we are relieved that the Senate did not adopt legislation that would have harmed patients and critical safety net programs, the status quo is not acceptable,” David O. Barbe, MD, president of AMA, said in the association’s statement.

“The first priority should be to stabilize the individual marketplace to achieve the goal of providing access to quality, affordable health coverage for more Americans,” he said.

ACP applauded the Senate’s rejection of the “skinny repeal,” noting that it had potential to greatly harm patients and would have left tens of millions of Americans without health insurance coverage.

“No version of legislation brought up this year would have achieved the types of reforms that Americans truly need: lower premiums and deductibles, with increased access to care,” Jack Ende, MD, MACP, president of ACP, said. “We need improvements to our health care system that protect the most vulnerable among us — the sick, the poor, the elderly. And we need improvements that stabilize the health insurance market places.”

“We now urge the House and the Senate to move forward in a bipartisan manner, working through ‘regular order,’ to make improvements to the ACA,” he added. “We welcome the opportunity to work together to improve and build on current law in a way that would make health care better and more affordable for our patients.”