ACA Repeal and Replace: If At First You Don't Succeed...

Mar 31, 2017

Last week, House Republican Leadership, in consultation with President Trump and his top advisors, decided to pull the American Health Care Act (AHCA) - the legislation to repeal and replace the Affordable Care Act (ACA) or Obamacare - minutes before the entire House of Representatives was set to vote on the legislation.  The bill, one of President Trump’s signature policy agenda items, would have made several changes to the ACA by eliminating the individual mandate, expanding the use of health savings accounts, restricting the amount of money for subsidies to eligible patients, eliminating Medicaid expansion and imposing per-capita caps on Medicaid spending with states having the option to opt-in to a Medicaid block grant, and repeal most ACA taxes among other things.


The decision to not vote on the legislation came amidst discussions between the conservative Freedom Caucus and the more moderate sects of the Republican Party.  The Freedom Caucus had several concerns with the legislation especially as it pertains to the refundable tax credit provisions ­ decrying them as another government entitlement program.  Moderate Republicans expressed concern with the analysis from the Congressional Budget Office (CBO) that the AHCA could increase the number of people without insurance by 24 million, that older and poorer people would face the brunt of higher medical costs, and the Medicaid reforms were too severe.  In light of these differences, Republican Leadership was unable to bridge the gap and secure the necessary votes to pass the legislation.  Instead of forcing members to vote on a bill they knew would not pass, Speaker Paul Ryan (R-WI) pulled the legislation.


In the wake of the decision to move on from consideration of the AHCA, President Trump and Congressional Republicans are left to determine next steps on their health care agenda.  President Trump and Speaker Ryan have indicated that health care reform is set aside temporarily and that they still have a desire to repeal and replace the ACA.  However, some within the Republican Party have publicly voiced their desire to move away from the AHCA legislation and start anew, recognizing some Democratic support may be needed to move a bill across the finish line.  What this potential legislation could look like is still unclear but some Members of Congress like Senator Bill Cassidy (R-LA) contends that a bipartisan, piecemeal approach that addresses certain parts of the ACA is needed and that a large comprehensive package is extremely difficult in this political environment.  There are also ways that Health and Human Services Secretary Tom Price could make modifications to the ACA, but without the corresponding legislative changes, it could further destabilize the already fragile health insurance market.


As Congress and the Administration mull these options, they must also proceed with other must pass health care legislation such as reauthorization of the Children¹s Health Insurance Program (CHIP), Medicare extenders, and the various user fee programs for prescription drugs and medical devices.  The Medicare extenders package presents an opportunity to move legislation related to pharmacist provider status (S.109 and H.R.592), which increases patient access to care in medically underserved areas by reimbursing pharmacists for services under the Medicare Part B program.  Additionally, the increased pressure to act on proposals related to prescription drug pricing could bring greater awareness to issues like direct and indirect remuneration (DIR) fees and maximum allowable cost (MAC) transparency.  Regardless, despite the setback on ACA repeal and replace, health care will still be a priority issue even though it may not be front and center.


AmerisourceBergen will continue to monitor developments with respect to health care reform as well as key pharmacy issues related to fair reimbursement, access to patients, and provider status.