Deep divisions over AHCA, but new vote may come this week

By the CDHP team

House Republicans remain divided on a bill called the American Health Care Act (AHCA), but a vote on the bill could be called this week. CDHP continues to monitor developments closely and is working collectively with our allies. We urge you to consider reaching out to your members of Congress about the AHCA bill. Check the end of this article for links to more resources.

The latest version of the AHCA would make major changes to the Affordable Care Act (ACA), including eliminating the individual and employer mandates, cutting premium tax credits for many families and weakening price protections for older Americans. More importantly, under the guise of cost-savings, the bill will make massive cuts to Medicaid, shifting the program’s financing to a per-capita caps or block grants, and allowing states to make changes to children’s EPSDT benefits, including oral health coverage.

All three types of waivers in AHCA should deeply concern health and children's advocates.

By the Congressional Budget Office’s estimates, the AHCA would cut $880 billion from state funding, leaving more than 20 million Americans without coverage over a 10-year period. Despite years of pushing for repeal, there is disagreement by House Republicans about their goals. While the most conservative wing of the party has sought to repeal as much of the ACA’s benefits and protections as possible (in the name of state flexibility), more moderate conservatives have been reluctant to agree to such drastic measures. Moderates point out that many of the ideas proposed would likely result in “pull[ing] the rug out from under” Americans who just benefitted from ACA’s expanded coverage, namely Medicaid.

Last week, Politico leaked an amendment to the AHCA introduced by Tom MacArthur (R-NJ) who proposed changes meant to appease conservatives and moderates. In particular, the amendment creates new waivers that would allow states to avoid regulations. All three types of waivers should be sources of concern for health advocates.

  • The first type of waiver will let states change the age-based pricing ratio, allowing insurers to charge older adults much higher premiums than their younger, presumably healthier, counterparts. As such, this provision has been dubbed the “senior tax.”
  • The second type of waiver will allow states to name their own Essential Health Benefits (EHBs). Under the ACA, EHBs define 10 categories of care that are required to be covered by marketplace plans as well as insurance products in the individual and small-group insurance markets. Currently, they cover services like maternity care, mental health and addiction, and a plethora of children's services, including oral health care. Although cutting EHBs would likely bring down the cost of coverage, it also means that insurers would not be required to cover the care someone might need if they fell ill or became pregnant. It could also significantly limit the services available to children, making preventive care far from comprehensive. Furthermore, it could mean that dental benefits for children are eliminated altogether.
  • The third waiver will allow states to let insurers practice health status underwriting, or charging someone for their insurance based on their health conditions or risk factors, thereby making insurance more expensive for people more likely to be ill. With this waiver, insurers could use this practice on anyone who lets their insurance coverage lapse, so long as the state is taking action to “manage” more expensive, high-risk populations (e.g., high risk pools). There is no individual protection for anyone who gets priced out of insurance. In effect, these waivers would eliminate the ACA’s protections for people with pre-existing conditions.

The amendment to the AHCA bill makes Medicaid waivers riskier. 

Last but not least, this amendment makes waivers riskier. Currently, states must provide evidence to the Department of Health and Human Services (HHS) showing their change will create benefits, but this proposal flips that relationship. Applications for waivers are automatically approved if a state shows intent to improve their local insurance market, and the onus is on HHS to find proof for rejecting an application. So states can make major changes without evidence, and the pressure is on HHS staffers to protect the interests of citizens.

Thanks to the ACA, Medicaid, and the Children’s Health Insurance Program (CHIP), dental coverage and access to oral health care are at an all-time high, especially for children. In addition, the ACA’s Medicaid expansion has provided millions more adults with dental coverage. We ought not to stifle this trend. The AHCA was already alarming for the future of oral health coverage and access, and this amendment makes that future even more uncertain. Cuts to Medicaid, weakening consumer pricing protections, and waiving essential health benefits may cut costs for insurers in the short term, but it would undo much of the progress we’ve made in improving oral health. That’s not a future we want to see.

With Congressional budget issues squared away, this health care plan may soon get the spotlight again. With that in mind, we encourage you to get involved in the conversation. You can:

  1. Reach out to your elected representatives and let them know that oral health coverage is a priority, and that you don’t support the AHCA.
  2. Learn more about the AHCA by taking a look at our “Why Dental Health Coverage Matters” Tool-Kit, which includes links to previous blog posts, recordings of our webinars, and examples of letters we’ve shared with Congress.
  3. Join us for a webinar specifically about waivers and local advocacy on May 9th with guest speakers Sara Rosenbaum and Peter Damiano.

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