What now for health care reform after a first try fails?

The decision by Speaker of the House Paul Ryan to withdraw from the House of Representatives the Republican bill to repeal and replace the Affordable Care Act (ACA), just minutes before the vote was scheduled to occur, was a huge victory for ACP advocacy and, most important, for the millions of patients who stood to lose coverage and benefits.

The College played a leading role in organizing opposition to the bill. We wrote several times to Congress to urge that it "First, do no harm" to patients by rolling back existing coverage and consumer protections established by the ACA. We formed a coalition with four sister professional medical societies—the American Academy of Family Physicians, the American Osteopathic Association, the American Academy of Pediatrics, and the American Congress of Obstetricians and Gynecologists, collectively representing more than 500,000 physician and medical student members—to lobby against repeal. And then-ACP President Nitin S. Damle, MD, MS, MACP, and I did numerous television and radio interviews to make the case about the harm to patients that would have occurred if the repeal and replace bill, called the American Health Care Act (AHCA), had become law.

It's important to recap the harm that could have occurred from the legislation. The Congressional Budget Office and other independent studies found that 24 million people would have lost coverage over the next decade, 14 million by next year. The bill would have made private health insurance much more expensive for older and sicker patients, because the tax credit subsidies it provided would have been inadequate to purchase affordable coverage. The bill also would have raised deductibles for most people, since it repealed the ACA's cost-sharing subsidies for people with incomes up to 250% of the federal poverty level.

The bill would have repealed federal requirements that Medicaid and private health insurers cover 10 categories of essential benefits, like prescription drugs, maternity care, and physician and hospital visits. The likely result is that many insurers in the individual insurance market would have dropped such coverage. Finally, the legislation would have radically restructured Medicaid, capping the federal contribution and ending the higher federal contribution to states that expanded Medicaid to people with incomes up to 138% of the poverty level. Altogether, the federal government's contribution would have been cut by $890 billion, a whopping 25% reduction, over the next 10 years. The loss of federal funding would have given states no choice but to reduce eligibility and benefits for many of the 70 million-plus patients now covered by Medicaid.

Our message was heard. Speaker Ryan withdrew the bill rather than see it get voted down in the House because of the intense opposition it engendered. Congressional offices reported that calls from constituents were running 47 to 1 against the bill, according to the Washington Post. A Quinnipiac poll taken right before the vote was scheduled to occur showed that the bill was supported by only 17% of voters.

Faced with the voter backlash, House Republicans were deeply split, with many conservatives opposing the AHCA because they felt it didn't do enough to repeal the ACA lock, stock, and barrel and moderates opposing it due to concerns about the impact of Medicaid cuts, loss of essential covered benefits, and higher premiums and deductibles on their constituents. Democrats uniformly opposed the legislation. Neither President Trump nor Speaker Ryan could bridge the divide, leading to the last-minute decision to withdraw the AHCA rather than see it voted down.

That the bill is dead, at least for now, doesn't mean that the country can just move on and forget about health care reform. The Trump administration now has a choice. It can help ensure that people have more choices of affordable coverage in every market throughout the country, or it can sabotage the insurance markets through action or neglect, causing more insurers to pull out and potentially leaving millions without any source of affordable coverage.

For instance, it can entice more insurers to sell insurance through the ACA marketplaces by helping those insurance plans that experience adverse selection (not enough young people signing up) get reinsurance to cover their losses. Or, it can decide that it won't lift a finger to help insurers stay in the market or to encourage people to sign up for coverage. It also needs to decide whether it is going to be supportive of more states taking up the option to expand Medicaid to lower-income persons and whether it will allow states to impose work restrictions on Medicaid enrollment, such as by requiring enrollees to have a job or be in a job training program as a condition of eligibility. ACP supports voluntary job training programs but is opposed to making work a condition for eligibility.

The Republican leadership in Congress also has a choice. At the time this article went to print, there were reports that the House leadership and the White House had restarted negotiations, especially with hardline conservatives, on a new repeal-and-replace bill that would be brought back to the House for a vote, this time to pass, presumably with enough commitments from conservatives (and without losing more moderates as a result of moving the bill in an even more conservative direction). While threading this needle will be difficult, it can't be counted out. And then, it would be up to the Senate to decide the new bill's fate, where moderate Senate Republicans could hold sway over the final outcome.

There is another, better way. Congress should put aside, once and for all, the terribly flawed policies in the AHCA, including the Medicaid funding caps, repeal of essential benefits, and the higher premiums and deductibles that would have resulted. Congress should instead work on a bipartisan basis to shore up the markets, give people more choices of coverage, and protect coverage for the most vulnerable covered by Medicaid. It should also work with us to tackle high prescription drug costs, enact medical liability reform, and reduce the crushing administrative paperwork burden on physicians and patients alike. This is an agenda ACP would strongly embrace and, more important, one that would have the strong support of the American people.