House passes first bill to expand the ACA

Photo: Robert Couse-Baker via Flickr

The House recently passed a health reform bill – and it’s a definite win for the incrementalists.

The Democratic presidential primaries – which now feel like they took place in another universe, long ago and far away – were animated by a significant divide over whether to move to a single-payer “Medicare for All” health care system or to build upon the Affordable Care Act. Presumptive Democratic nominee Joe Biden wants to build on the ACA and favors adding a public option.

But what the House Democrats did in the late June vote is narrower than either of those approaches – although it’s more of a 2020 political statement than a full-bore health policy agenda for 2021. (Here’s the bill text.)

It doesn’t contain particularly controversial ideas (at least not controversial among Democrats). There’s no public option, nor enlarged role for government in delivering health care, so it’s not likely to cause any political headaches for moderate Democrats running for re-election in more conservative areas. Nor is the GOP-led Senate likely to take it up.

But the bill is the first to pass the House to expand the health law since it became law a decade ago. And it allows Democrats to put themselves on the record expanding coverage and making it more affordable going into the fall elections ― as President Trump backs a lawsuit pending in the Supreme Court that would topple the ACA.

“Make no mistake, a vote against this bill is to weaken Americans’ health and financial security during a pandemic,” said House Speaker Nancy Pelosi.

The bill would change subsidies ― technically called premium tax credits ― to buy insurance through the exchange. The ACA currently provides subsidies to people with incomes up to 400 percent of the federal poverty level, which is a bit more than $50,000 for an individual and around $105,000 for a family of four. Instead of those thresholds, the House bill would say that nobody has to pay more than 8.5 percent of income on an ACA plan (pegged to the most popular tier).

It also encourages hold-out states to expand Medicaid by offering them the full federal subsidy for three years. Washington picked up the tab for up to three years for states that expanded in the early years, then scaled back the subsidy to around 90 percent. Currently, there are 14 hold-out states, but Oklahoma voters just passed an expansion initiative, and a similar measure goes to Missouri voters next month.

The legislation also addresses the long-running debate over drug costs by including a requirement for the government to negotiate prices.

For a more detailed discussion of the secondary measures in the bill, see this Health Affairs blog post.

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