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Why Republicans aren’t winning the argument over preexisting conditions

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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House Republican leaders are trying to drag their health care bill across the finish line by convincing moderate lawmakers that the bill does not undermine Obamacare's protections for people with preexisting conditions. That has become the primary hurdle, along with the bill's Medicaid cuts, to getting the votes it needs from the centrist wing of the GOP.

"VERIFIED: MacArthur Amendment Strengthens AHCA, Protects People with Pre-Existing Conditions," the subject line of one example, a press release from House Speaker Paul Ryan's office, read Tuesday.

But the problem for Ryan — and President Trump, who has been making the same argument — is that lawmakers in their own party are directly contradicting them.

They have good reason. Republicans have tried to patch together a policy to address these concerns, but the result is still a bill with weaker protections for people with preexisting medical conditions than those provided by Obamacare.

The MacArthur Amendment, the latest change to the health bill, would change the rules for these people in a few ways:

  • States could apply for a waiver to opt out of Obamacare's rule that prohibits health insurers from charging sick people more than healthy people. So insurance for people with preexisting conditions might technically still be on the market, but premiums could be so high that many of those people couldn't afford it. That's the big problem for many moderates (and therefore House leaders).
  • Ryan's release says states would have to argue the change would, for example, lower premiums in order to get the waiver approved. The bill itself, though, makes approval effectively automatic unless the federal government stops it.
  • States would also be required to set up a high-risk pool, where sick people could buy coverage, in exchange for a waiver. But the historic problem for high-risk pools has been that they didn't have enough money to cover sick people, and Larry Levitt at the Kaiser Family Foundation told me the AHCA has the same problem. The money included in the bill is also less than what conservatives have projected is necessary for high-risk pools to work.
  • People could also not be discriminated against if they maintained health coverage, another defense deployed by the bill's defenders. But if you do let your insurance slip, you're out of luck. So that still isn't the same level of protection that Obamacare offers.

All of this is making some House Republicans balk.

House leaders have lost two critical votes in the past two days: Billy Long, a solid conservative for a solid-red district, and Fred Upton, who until this year chaired the Energy and Commerce Committee, which covers a lot of health care policy. Both cited the loss of protections for people with preexisting conditions in explaining their opposition.

“I have always stated that one of the few good things about ObamaCare is that people with pre-existing conditions would be covered,” Long said in a statement. “The MacArthur amendment strips away any guarantee that pre-existing conditions would be covered and affordable.”

Upton — who had authored Obamacare repeal plans in the past — said more or less the same thing.

"We've talked about the protection for those with pre-existing illnesses for the last number of years," he said. "We're not going to budge either."

So as leadership tries to persuade the wavering moderates to back the health care bill, they're being undermined by a solid Missouri Republican and a lawmaker with a deep background in health care policy.

It's not making their jobs any easier, as two members of the centrist Tuesday Group who do support the bill told me. I asked MacArthur and Rep. Chris Collins, a longtime Trump supporter, about Upton's defection and whether that complicated their argument.

"There is no question," Collins said, though he did return to the idea that the waivers were misunderstood.

MacArthur said he and Upton had discussed the waiver extensively but hadn't been able to reconcile their views.

"I just see this differently. Maybe it's 30 years in insurance," he said. "Fred and I disagree on this issue, but I have all the respect in the world for him."

Chart of the Day

Brookings Institution

Employer coverage and out-of-pocket limits. So much attention is paid to how Obamacare changed the individual market and Medicaid. But one big change to the employer market — where about half of Americans get their coverage — is the near elimination of insurance plans that had no limit on what people could spend on health care out of pocket. Read more from the Brookings Institution here.

Kliff's Notes

With research help from Caitlin Davis

  • "In a state that loves Obamacare, Republicans could kill Trump’s hope of ending it": “One California House Republican is 'listening to his constituents' about health care reform. Another is 'still studying' the issue. A third, one GOP press secretary said, is 'reviewing the text.' The one thing most aren’t doing is committing themselves to supporting a bill to repeal and replace Obamacare that’s a top priority for the Trump administration but is particularly unpopular in California.” —Sean Cockerham and Michael Doyle, McClatchy
  • "The health care bill's path forward in the Senate": “It's been widely assumed the current GOP health care bill working its way through the House would be vastly changed in the Senate — in fact, that's part of leadership's pitch to moderate holdouts. But Senate Republicans are already thinking about what it will take to get the bill through the upper chamber, and the changes are not as vast as some might think.” —Caitlin Owens, Axios

"CEO out at top Obamacare insurer Molina Healthcare": “The ouster comes about a week after Molina threatened to leave all of Obamacare's exchanges if it didn't get cost-sharing reduction payments from the Trump administration. While Trump will make the payments in the short term, he has said he wants to see what happens with an Obamacare repeal bill before deciding to fund them next year.” —Robert King, Washington Examiner

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