WASHINGTON -- The House passed a Tuesday, which includes a repeal of the Affordable Care Act's individual insurance mandate, by a vote of 227-203 -- but an issue that came up in the Senate means the House will have to vote yet again, most likely on Wednesday.
After the House voted on the bill, that certain provisions in it violate Senate rules and will have to be changed. After the Senate passes the revised bill (expected to happen late Tuesday or early Wednesday), it will have to go back to the House for a re-vote and then on to President Trump for his signature.
The House vote was largely along party lines, although 12 Republicans voted against it. No Democrats voted for the bill, and two Democrats didn't vote.
In debate on the House floor, Democrats and Republicans presented two very different views of the mandate repeal. "The final bill is worse than we feared," said Rep. Rosa DeLauro (D-Conn.). "It repeals a key element of the ACA, kicking 13 million off of health insurance and raising premiums by 10%."
That's not how House Speaker Paul Ryan (R-Wisc.) saw it. He said that repealing the mandate, which requires people to purchase health insurance or pay a penalty, "is restoring freedom to make your own healthcare choices; it's the freedom to buy healthcare that's right for you and your family."
The bill also had other provisions affecting healthcare, including allowing people to deduct medical expenses from their taxes. Under current law, medical expenses are deductible if they comprise at least 10% of income; under the tax bill, that percentage is . In addition, interest on student loans -- including medical school loans -- remains tax-deductible; that deduction was removed in the original House bill.
The repeal's potential effect on the health insurance market isn't easy to tease out, Robert Laszewski, president of Health Policy and Strategy Associates, a consulting firm in Alexandria, Virginia, said in an email.
Overall, "there will be many more uninsured, if only because the current exchange enrollment will be down by a significant number compared to last year," he said. "Will that be because of the individual mandate repeal, or because the policies cost too much in 2018, or because of Republican sabotage? It's hard to say just how much of it can be pinned on any one cause. But there will be many fewer insured."
The mandate repeal actually doesn't take effect until 2019, Laszewski noted, "but I doubt many consumers knew that when they decided not to sign up during all of the news reports about the individual mandate being repealed."
Thomas Miller, JD, resident fellow at the American Enterprise Institute, a right-leaning think tank here, sees the repeal as “more of a ‘mercy killing’ (putting it out of its chronically ineffective and unpopular misery),†he said in an email. As to whether more people will become uninsured if the mandate is repealed, “Self-serving claims by insurance sector interests and diehard ACA defenders that mandate repeal will trigger widespread disruption and despair in health care markets are vastly exaggerated, as long as other coverage subsidy dollars from taxpayers keep flowing. Good riddance to a half-hearted effort at trying to coerce some mostly less-affluent Americans into buying coverage they did not want, could not afford, or both.â€
Laszewski said the medical expense deduction “will be a great relief to families who have a loved one in a nursing home or with an expensive chronic disease.†But Miller was a little more cautious, noting that the deduction “has limited effects, given its still-high threshold and income-related deductibility benefits.â€
“It might be better structured to kick in at an even lower level, for expenses above 5% of adjusted gross income, as it once did many decades ago … But in the meantime, at least millions of Americans still with very substantial out of pocket medical expenses will gain somewhat more tax relief.â€
The lower threshold for medical expense deductions "will be a great relief to families who have a loved one in a nursing home or with an expensive chronic disease," he added.
The Association of Community Affiliated Plans, a trade group for safety net health plans, expressed its opposition to the bill. "[T]he repeal of the individual mandate and the modifications to the state and local taxes combined with the stated intent that an additional $1.5 trillion in federal debt created by this legislation will be used to justify dramatic and devastating cuts in federal health care programs like Medicaid, will have disastrous impacts on America's health care system," said ACAP CEO Margaret Murray in a prior to the vote.
During a press conference, White House spokeswoman Sarah Huckabee Sanders emphasized that repealing the mandate is just the beginning. "We've said all along that our healthcare system is broken," she said. "It has to be fixed; this is one step in that process ... We're committed to fixing the system as a whole and not just one element of it."