There are conflicting reports coming out of Washington, D.C. regarding whether the parliamentarian of the United States Senate has said that the American Health Care Act (AHCA) passed by the House of Representatives last month meets the rules for a simple majority vote. Republicans claim that the parliamentarian has ruled that the AHCA satisfies the requirements of the budget reconciliation process. Meanwhile, Democrats claim that the parliamentarian has only ruled that the bill as a whole meets the requirements, but has not yet ruled on specific provisions.
For the Senate to use the budget reconciliation process (which only requires a simple majority, rather than the 60 votes required in the Senate for most matters) the provisions in the bill must relate to the federal budget.
Among the provisions that many people think might be stricken by the parliamentarian because they do not relate directly to the federal budget are the provisions that:
- Allow states to apply for waivers to define essential health benefits
- Allow states to abandon community rating (which would mean people with pre-existing conditions could be charge more than healthy people)
- Allow health plans to charge older policyholders five times what they charge younger policyholders, rather than the three times currently allowed
- Allow insurers to place a 30% surcharge on premiums for people with gaps in coverage
- Allow states to impose work requirements for Medicaid recipients
- Turn Medicaid into a block grant program
- Create high-risk pools
The AHCA would repeal significant portions of the Affordable Care Act (ACA), including the penalties on individuals for failing to have minimum essential coverage and the penalties on employers for failing to offer coverage. Other significant provisions would eliminate the expansion of Medicaid in 2020 and change the subsidy provisions from one based on income and premiums to one based on age, with a phase-out for higher income individuals. Other provisions in the AHCA include expanding the limits for Health Savings Accounts and repealing most of the ACA’s taxes, but only delaying implementation of the so-called Cadillac tax until 2025.
Republicans can only afford to lose two votes in the Senate and still pass the bill (Vice President Pence would cast a vote in the case of a tie). According to knowledgeable lobbyists, there are more than three conservative Republican Senators who think the House bill spends too much money and leaves too much of the ACA in place. There are also more than three Republican Senators, mainly from states that expanded Medicaid, who want more Medicaid funding than is in the House bill.
Furthermore, there are at least three Republican Senators opposed to the provisions eliminating funding for Planned Parenthood and tax credits for policies that cover abortions. These conflicts explain why some people call the bill the Trumpcare Zombie.
Republicans also want to use the budget reconciliation process for tax reform; however, there can only be one budget reconciliation bill in process at a time, which means that the AHCA will need an up-or-down vote before Congress can address tax reform. Even if Republicans cannot manage to find 50 votes for the AHCA, it is probable that the Senate will vote on the bill in July to clear the way for tax reform.
The House has not yet sent the AHCA to the Senate because it is holding the bill, pending the ruling by the Senate parliamentarian, in case the House had to remove certain provisions.
Even though the Senate had not formally received the bill from the House, Senators have been in discussions about the bill. A number of Senators have said that the Senate will basically start over on the repeal and replace efforts, so whatever the Senate votes on may not look like the version of the AHCA approved by the House.
If there are changes to the bill, which is highly likely, the House would have to approve the new bill before it would go to the President for signature. Even if the Senate can come to an agreement on a bill, it is possible that the House would not approve it.