Health Care News, Health Center Federal Policy

As Congress Returns, Leaks, Rumors and Disagreements Dominate the ACA Debate

By Oliver Spurgeon and John Sawyer, NACHC Federal Affairs Team

Normally, a Congressional recess, where Members travel home to hold meetings with constituents in their districts, is a relatively quiet time for those of us in Washington. Staffers on the Hill don jeans in lieu of suits, and may pull back to working 8 or 10-hour days, rather than the typical 12+. For those of us following the health care debate in Washington closely, however, last week’s recess was anything but boring.

Friday morning, a leaked and dated draft of House Republicans’ budget reconciliation bill ‒ their initial ideas to repeal the Affordable Care Act (ACA) ‒ landed in inboxes across Washington as lobbyists and staffers were finishing their morning coffee. Judging by the crooked pages, missing page numbers, and numerous pen scribbles throughout the document, the effort is far from complete. Yet after almost 7 years of Congressional pledges to “repeal and replace” the Affordable Care Act (ACA), and roughly two months of relative inaction on Capitol Hill, the draft bill does provide more detailed insight into thinking amongst House leaders than had previously been available. The bill would roll back the ACA Medicaid expansion, replace the ACA premium subsidies (which are determined based on income) with tax credits based on age, make funds available to States to create high-risk pools or other “innovations,” and would attempt a major structural change to the Medicaid program – shifting away from the current entitlement structure to one where federal contributions are capped. A good summary of the provisions is available on Health Affairs’ blog here.

Yet the leaked draft was also quite dated, with a date-stamp indicating it was current thinking as of February 10th. Two weeks is a lifetime in politics, as they say – and the same goes for complex legislation. This rule of thumb definitely applies as bills get more complex, and can often result in first drafts and final products that are miles apart in terms of content and outcomes. The 2009-2010 effort to pass the ACA is a testament to that rule. Remember, after 15 months of debate ‒ passing a major bill through Congress was and still is a slow and tedious process ‒ the House’s initial draft of the ACA and the version signed into law looked nothing alike.

Friday also marked the beginning of the annual meeting of the National Governors Association here in Washington. Considering how intertwined the ACA is with state-level policy and politics, the nation’s Governors are expected to be among the most important voices as Congress considers health policy this year. So what emerged from the Governors discussions? More disagreements, even among the majority Republican governors, and more leaks.

Medicaid seems to be the main flashpoint, understandably, for the governors. Specifically, documents leaked to and subsequent reports suggest that Republican governors are still in very different places from one another when it comes to the Medicaid expansion question, and the details of proposed structural changes like a per-capita cap or block grant. Disagreement among governors tends to make especially Senators very hesitant, since mostly Senators don’t like to go against their own state’s governor – especially when they come from the same party.

On the eve of Congress’ return, more disagreements came into the open. On Monday night, Rep. Mark Walker (R-NC), Chair of the conservative House Republican Study Committee, and Rep. Mark Meadows (R-NC), Chair of the even more conservative House Freedom Caucus, both announced that they could not support the House bill if it resembles the leaked draft. Together, Walker and Meadows represent well over 100 members of the House Republican Conference. So, without Democratic support, no bill is likely to pass if either of these groups is opposed, much less if both of them are.

All of this taken together suggests that Congress is actually quite a bit further from resolving the “repeal/replace” issue than anyone initially thought. If you need further proof that Congress remains in the starting blocks on healthcare reform, just look at of all the organizations still providing ideas to Republicans and Democrats in the House and Senate. Doctors and hospitals continue to beat the drum of patient access, and insurers, drugmakers and governors are all amongst those visiting with the Trump administration over the last couple of weeks. And of course, health centers are still weighing in with everyone involved in this process to highlight and promote the value and impact of our national system of care.

Bottom line? While we need all advocates to stay engaged in the debate (check out our fabulous new advocacy website, for any number of ways to do so), it’s also vital that we stay focused on the health center message, and that we not bet the farm on leaks, rumors, or innuendo. In the meantime, the Federal Affairs team here at NACHC will continue to monitor developments on the Hill, and ensure that the voices of health centers are represented at the negotiating table. Continue to follow Health Centers on the Hill for future updates, plan to join us for the next monthly Policy and Advocacy Webinar on March 21st, and most important, come make the case in person during the 2017 NACHC Policy and Issues Forum.

If you have any additional questions, comments, or concerns, or just want to learn a little more about buzzwords like “per capita caps” and “block grants,” please feel free to contact us at