HR 1884

Last evening, over three years after I posted my "If I Ran the Zoo" wish list of recommended improvements for the ACA, the U.S. House of Representatives finally passed H.R. 1425, the Patient Protection & Affordable Care Enhancement Act (#AHEA), which I simply dub "ACA 2.0":

House Democrats on Monday passed a bill that would bolster the Affordable Care Act by hiking premium subsidies and incentivizing states to expand Medicaid.

I wrote up a detailed, step-by-step explainer of all 30 provisions of the ACEA last week, and couldn't be happier to see it finally pass through at least one Congressional body.

Unfortunately...

OK, this surprised me a bit: #HR1425, the Patient Protection & Affordable Care Enhancement Act, has already received a 10-year budgetary impact score from the Congressional Budget Office. I don't think this is a formal score--the whole thing is only five pages and includes minimal text accompanying it, so it might be just a "draft" score or something. I presume that if Mitch McConnell were to shock everyone and actually give it a vote in the Senate (which won't happen), there would likely have to be a second, more elaborate scoring process done by the CBO first. Then again, perhaps not.

Anyway, in a nutshell, the CBO report on the House version of H.R. 1425 comes to the following conclusions regarding the budget impact and other, related results of the bill being implemented nationally. Keep in mind that this assumes that the bill became law and was implemented starting in 2021; the score includes the 10 year period from 2021 - 2030:

TITLE I: Lowering Healthcare Costs & Protecting People w/Pre-Existing Conditions:

OK, I don't know if I "scooped" everyone with my H.R. 1425 explainer yesterday or what, but the House Energy & Commerce Committee just now sent out an official press release announcing the bill, along with a one-page summary, more detailed explainer and the link to the text itself. It's kind of interesting to see what language they use and which sections they emphasize, espeically as compared & contrasted with my own write-up:

Health Committee Chairs Unveil Legislative Package to Make Health Care & Prescription Drugs More Affordable

Legislation Also Expands Access to Health Care, Protects People with Pre-Existing Conditions & Reverses Administration’s Ongoing Sabotage of the ACA

Back in early March (a lifetime ago given the events of the past few months), House Democrats were on the verge of finally voting on a suite of important ACA protections, repairs and improvements which I've long dubbed "ACA 2.0" (the actual title of the first version of the "upgrade suite" bill was ridiculous when it was first introduced in 2018, and the slightly modified version re-introduced in 2019 was somehow even worse, no matter how good the bill itself was).

The game plan was to hold a full floor vote in the House on H.R. 1884 (or possibly a slightly different variant) the week of March 23rd, 2020 to coincide with the 10th Anniversary of the Affordable Care Act itself. This would have made perfect sense both symbolically as well as policywise, as the ACA desperately needs a major upgrade (and it would've needed one even without years of Trump/GOP sabotage, I should note).

Regular readers may have noticed that after a 3-4 month hiatus, I've recently started writing several stories touting "ACA 2.0"-type bills again over the past week or so.

First, last Tuesday, I dusted off my "How much would H.R. 1868 lower YOUR premiums?" series, in which I look at real-world examples of the impact of killing the ACA subsidy cliff (i.e. the 400% FPL income eligibility threshold) and beefing up the underlying subsidy formula in specific parts of the country. Then, on Monday, I wrote an updated explainer of a newer bill, H.R. 6545, an Age-Based subsidy enhancer, which I'm touting as a perfect companion bill to go alongside H.R. 1868.

For several years now, I've been urging Congress to upgrade the Affordable Care Act via a series of major improvements. Most notable among these is the need to #KillTheCliff...that is, to eliminate the so-called "Subsidy Cliff" which kicks in for ACA individual market enrollees who earn more than 400% of the Federal Poverty Line (roughly $50,000 for a single adult or $103,000 for a family of four).

As I've explained many tmes, the ACA's subsidy structure works pretty well for those earning between 100 - 200% FPL, and is at least acceptable for those earning 200 - 400% FPL (in fact, thanks to #SilverLoading, it works quite well for most of that population as well). The real problem kicks in above 400% FPL (and to a lesser extent below 138% FPL for those living in the 14 states which still haven't expanded Medicaid). In addition, the subsidy formula still doesn't make policies truly affordable for many of those receiving them.

In short, both the upper- & lower-bound Subsidy Cliffs need to be eliminated, and the underlying formula needs to be strengthened as well.

For several years now, I've been urging Congress to upgrade the Affordable Care Act via a series of major improvements. Most notable among these is the need to #KillTheCliff...that is, to eliminate the so-called "Subsidy Cliff" which kicks in for ACA individual market enrollees who earn more than 400% of the Federal Poverty Line (roughly $50,000 for a single adult or $103,000 for a family of four).

As I've explained many tmes, the ACA's subsidy structure works pretty well for those earning between 100 - 200% FPL, and is at least acceptable for those earning 200 - 400% FPL (in fact, thanks to #SilverLoading, it works quite well for most of that population as well). The real problem kicks in above 400% FPL (and to a lesser extent below 138% FPL for those living in the 14 states which still haven't expanded Medicaid). In addition, the subsidy formula still doesn't make policies truly affordable for many of those receiving them.

In short, both the upper- & lower-bound Subsidy Cliffs need to be eliminated, and the underlying formula needs to be strengthened as well.

Two years ago, Democratic Congressmen Frank Pallone, Bobby Scott and Richard Neal introduced the awkwardly-titled "Undo Sabotage and Expand Affordability of Health Insurance Act of 2018", which really amounted to a suite of improvements and strengthening of the Affordable Care Act which I simply labelled "ACA 2.0".

At the time it was purely a messaging bill, of course, since the Democrats were in the minority in the House and Senate, as well as obviously not having control of the White House either.

Almost exactly a year later, the situation had changed: Democrats were still out of power in the White House and Senate, but they had flipped the House of Representatives on a promise of working to protect, repair and strengthen the ACA. Sure enough, the same ACA 2.0 bill was re-introduced with a few tweaks and a new, even clunkier name: The Protecting Pre-Existing Conditions and Making Healthcare More Affordable Act.

As healthcare reporter Kimberly Leonard put it at the time:

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

Last March I wrote an analysis of H.R.1868, the House Democrats bill that comprises the core of the larger H.R.1884 "ACA 2.0" bill. H.R.1884 includes a suite of about a dozen provisions to protect, repair and strengthen the ACA, but the House Dems also broke the larger piece of legislation down into a dozen smaller bills as well.

Some of these "mini-ACA 2.0" bills only make minor improvements to the law, or make improvements in ways which are important but would take a few years to see obvious results. Others, however, make huge improvements and would be immediately obvious, and of those, the single most dramatic and important one is H.R.1868.

The official title is the "Health Care Affordability Act of 2019", but I just call both it and H.R.1884 (the "Protecting Pre-Existing Conditions and Making Health Care More Affordable Act of 2019") by the much simpler and more accurate moniker "ACA 2.0".

A few weeks ago, I threw a bit of cold water water on the Medicare for All vs. Public Option brouhaha by pointing out that:

  • a) No complete overhaul of the U.S. healthcare system is going to happen before 2021 at the very earliest anyway; and
  • b) Regardless of what the hypothetical overhaul ended up looking like (M4All, Med4America, or a Public Option), it would likely take a couple of years of going through the legislative and regulatory process before actually going into effect; and that therefore...
  • c) In the short term (i.e., the next 2-3 years at least) what we should really be focusing on is protecting, repairing and strengthening the ACA itself, via a robust ACA 2.0 bill package.

As I reminded folks, there are two excellent ACA 2.0 bills which have already been introduced in both the House and Senate, with many overlapping provisions: In the House, it's H.R. 1884...which has also in turn been broken out into about a dozen smaller, standalone bills (several of which have already passed through the full House). In the Senate, it's S.1213, the Consumer Health Insurance Protection Act or CHIPA. As far as I know, the Senate version is a single package bill and has not been broken out into smaller chunks.