UPDATE x2: Cat's Out of the Bag: Some sort of ACA 2.0 bill will indeed be voted on by the House this month!

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.

As you may have guessed, the timing of these articles isn't a coincidence. I've heard rumors from at least three sources that House Democrats are indeed planning on voting on some sort of "ACA upgrade" bill later this month. They actually attempted to squeeze a bill of this nature into several of the "must-pass" COVID-19 emergency response bills, such as the "Take Responsibility" bill, the CARES bill and the HEROES bill, but it didn't make the final cut in any of them.

Instead, they've apparently decided to pass an ACA upgrade as a standalone bill. It won't go anywhere in the Senate under Mitch McConnell's "Grim Reaper" policy, of course (and even if it did, Trump would obviously veto it, given that he's still hell-bent on seeing the entire ACA struck down by the U.S. Supreme Court), but it would make for a hell of a campaign messaging bill by reminding Americans which party stands for expanding healthcare coverage and reducing out of pocket costs to the enrollees...and which party stands against those things.

Today, Kimberly Leonard of Business Insider confirms the rumor and has the inside scoop on the bill in question:

Democrats are preparing a House vote in about two weeks on a bill that they're calling an "enhancement" to the Affordable Care Act, former President Barack Obama's signature health law, which brought insurance coverage to more than 20 million people.

The bill doesn't have any chance of becoming law, because it won't be taken up by the Republican-controlled Senate. Instead, it's meant to set a contrast between Democrats and Republicans ahead of the 2020 elections, by positioning Democrats as the party that wants to help more people get healthcare at a lower cost in the middle of a pandemic.

As for what's actually in the bill, Leonard lists five key elements (though she also notes that the exact language hasn't been locked in as of yet, so some of this could change):

  • "Making ACA subsidies more generous" and "bringing the cost of premiums, deductibles & co-pays in the ACA down"...the article doesn't explicitly state that the bill would kill the 400% FPL subsidy cliff, but it's heavily implied, seeing how H.R. 1884 (the "parent" bill which includes H.R. 1868 within it) has 162 sponsors. It's also possible that H.R. 6545 made the cut as well, which would be fantastic.
  • Reinstating Obama-era restrictions on #ShortAssPlans...as I've explained many times before, so-called "Short-Term, Limited Duration" healthcare plans are dirt cheap...for a reason: They tend to be "junk insurance" with massive loopholes, lots of fine print, tons of exclusions, and the ability to discriminate against those with pre-existing conditions. These are essentially the very types of plans which the ACA was hoping to eliminate...yet the wording of the ACA didn't actually do so. They were heavily restricted under the Obama Administration, but Trump removed those restrictions. Again, a standalone bill (H.R. 1010) was passed by the House last May which would have set things back to Obama-era rules on STLDs, but it went nowhere in the Senate.
  • Expanding Medicaid eligibilty for new low-income mothers from 60 days to 12 months

All of these provisions would be important improvements to the ACA, especially if the bill really does completely #KillTheCliff and beef up the subsidy formula. The article does stress at the end that no, it would not implement the national Public Option being pushed for by Joe Biden, nor would it include expanding Medicare to those aged 60-64. And really, none of the bullets above are surprising to me; the only one which is new to me is the 2-month-to-12 month expansion of Medicaid for new mothers.

HOWEVER, Leonard does mention one new proposal in the bill which is pretty dramatic if it went through:

  • Raising the ACA Medicaid expansion eligibility threshold from 138% to 200% FPL

Under the ACA as it stands, states can opt to expand Medicaid eligibility to all legally-present residents earning as much as 138% FPL (roughly $17,600/year for a single adult or $36,100 for a family of four), with the federal government picking up 90% of the tab. Those earning between 138% - 400% FPL are eligible for subsidized ACA exchange policies, of course, on a sliding scale. In the dozen or so states which haven't expanded Medicaid, of course, those not currently eligible for Medicaid who earn less than 100% FPL are pretty much screwed.

If the Medicaid expansion threshold were expanded to 200% FPL, that would be huge....because according to the Kaiser Family Foundation, a full 30% of the U.S. population earned less than 200% FPL in 2018. That's 99 million Americans. Of course, over 70 million Americans were already enrolled in Medicaid (or CHIP) as of February 2020 anyway, consisting of <138% FPL "able-bodied" adult crowd and other groups like the disabled, seniors, pregnant women, etc., so the total number of Americans who would become newly-eligible for Medicaid would presuambly be something like 30 million people, or nearly 10% more of the total population.

For comparison, 57% of 2020 HealthCare.Gov enrollees earn between 100-200% FPL. Assuming this is representative nationally, that means roughly 6.5 million of the 11.4 million current ACA exchange enrollees would be shifted over to Medicaid...and remember, that's all from before the COVID-19 pandemic caused a whopping 40 million Americans to lose their jobs.

Of course, I'd have to know more details about how the 138% - 200% expansion would work. Would the feds still pay 90% of the cost? They'd pretty much have to...but even the 10% paid for by the states would still increase dramatically as well. What about the states which still haven't expanded Medicaid? If they're unwilling to foot 10% of the bill for their sub-138% FPL residents, they sure as hell aren't gonna jump on it for even more people.

It's also conceivable that the bill could be more like a national Basic Health Plan (BHP) program, already working very successfully for nearly a million residents of Minnesota and New York. The BHP program is sort of a hybrid between Medicaid and subsidized ACA plans...enrollees have to pay a small, flat premium, but it's far more comprehensive than an ACA plan and can be enrolled in year-round.

Having said this, I obviously fully support a bill which does all of the above. It'll be interesting to see what the final version looks like. I'll be especially interested in seeing how one House member in particular votes on it: Former Democrat Jeff Van Drew (NJ-02), who infamously switched parties and became a Trump sycophant last December during the House impeachment vote.

You see, prior to his party switch, Van Drew was a co-sponsor of...H.R. 1884, the House "ACA 2.0" bill. And in fact, as of this writing, he's still listed as a co-sponsor, even if his party affiliation is wrong (it still lists a "D" next to his name).

UPDATE: Well, that was short-lived; Leonard has updated her story with this part about the 200% FPL Medicaid increase:

Democrats also had weighed a second provision that would have allowed millions more people to enroll in Medicaid by raising the income limits for the program. On Wednesday, however, a senior Democratic aide said that provision wouldn't be included in the legislation headed for a vote. 

Ah, well.

UPDATE 6/18/20: Kim Leonard has updated her story again with two additional tidbits:

  • The bill in question will receive a full House floor vote on June 29th, and...
  • The title of the bill will be...drumroll please...the "Affordable Care Enhancement Act" or #ACEA.

This may sound like a pretty silly thing, but the title, while not exciting, is a hell of a lot better than the previous versions I've written about:

  • In 2018: "The Undo Sabotage and Expand Affordability of Health Insurance Act", or #USEAHIA
  • In 2019: "The Protecting Pre-Existing Conditions and Making Healthcare More Affordable Act" or #PPECMHMAA

Needless to say, #ACEA is a whole lot easier of a hashtag to type and remember....