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Q&A: What is in the Republican health-care bill?

Q: Is the House vote Thursday to repeal the Affordable Care Act?  

A: Not entirely. In the past seven years since a Democratic Congress and the Obama administration pushed through the ACA, the House has taken more than five dozen votes to repeal all or part of it. But today's vote is a first-stage effort, with the bill designed — at least originally — to address only those parts of the sprawling law that have budgetary implications. It is designed that way to try to make it easier for the legislation to be passed in the Senate under a "reconciliation" process that allows bills with budgetary impact to be passed by a simple majority, rather than a filibuster-proof 60-vote majority.  

Q: So then what is and what is not in the House bill?  

A: In broad strokes, the legislation has a lot of financial aspects. For instance, it would substantially reduce the funding for subsidies that the ACA has provided to most people buying insurances through insurance marketplaces the law created and make other changes to those subsidies in ways that, overall, help younger adults and make premiums more expensive for older ones. The bill also would eliminate several taxes the ACA created to help pay for its provisions, including on health insurers. It would not eliminate the requirement that most Americans carry health insurance. Instead, it would get rid of the penalty imposed for not having insurance and create a new deterrent for not having coverage: a 30 percent surcharge that insurers could tack onto their rates.  

Q: Would this affect the number of people with insurance in the United States?  

A: Yes. According to an estimate of the original version of the bill by the Congressional Budget Office, 24 million more people would be uninsured by 2026. The CBO has not updated that forecast since House Republicans have been tinkering with aspects of the legislation in an attempt to secure enough votes.  

Q: Would Medicaid be affected?  

A: Absolutely. The GOP health bill would cut $880 billion from the Medicaid program over the next decade, according to the most recent CBO estimate. This program provides health coverage for low-income Americans and helps pay for long-term care for people with disabilities and seniors.  

Under the ACA, 11 million people have gained Medicaid coverage. For the next few years, the 31 states that have expanded their Medicaid programs under the ACA could keep going, but new people eligible under the expansion could not enroll. Then, starting in 2020, the program would switch to a very different method of federal payments, breaking with its history of paying a certain proportion for everyone enrolled and moving to a system in which each state would being given a certain amount per person — a change that critics predict would starve the program as time goes by.  

Q: How will the House GOP bill change protections for people with preexisting conditions?  

A: Under the ACA, insurers are prohibited from denying coverage to individuals based on preexisting medical conditions, such as cancer, depression or asthma. And the ACA requires insurers to offer "community rating," meaning they cannot charge those with costly medical conditions more than they charge other consumers in the general insurance pool.  

But the amendment crafted by Rep. Tom MacArthur, R-N.J., which will now be part of the American Health Care Act, allows states to obtain a waiver from the Health and Human Services Department that would let them charge customers with preexisting conditions more than other people. If HHS did not respond to a state's waiver request within 60 days, the requested change would automatically go into effect.  

Health experts predict that the result would be a sharp rise in premium increases for those with medical problems. Before the ACA became law, individuals with chronic diseases paid several times as much as others - if they could afford or be approved for a policy in the first place.  

Concerned about the effect the MacArthur amendment would have on those with long-standing medical conditions, GOP Reps. Fred Upton, Mich., and Billy Long. Mo., crafted a provision Wednesday that provides $8 billion to help these patients pay for increased premiums and out-of-pocket costs.  

Q: What are the budgetary implications of the recent changes?  

A: The CBO has not had time to review the changes Republicans have made to the bill, so it will not be providing a budget estimate before lawmakers vote on the measure Thursday. Before Republicans added $8 billion to the bill, the Committee for a Responsible Federal Budget said these alterations could save up to $5 billion or cost as much as $265 billion, since it's unclear how many states will seek waivers to change the benefits packages or the ratings rules that insurers must comply with under current federal law.  

According to a CBO estimate issued in late March, the House GOP plan would cut the federal deficit by $150 billion between 2017 and 2026. It would also result in 24 million fewer Americans people being insured by 2026.  

Q: What are the odds that the House bill would pass the Senate?  

A: Uncertain. Before the Senate could even consider the bill, it would need to pass muster with the Senate parliamentarian, who would scrutinize it to ensure it fit within the chamber's rules on considering only matters with budgetary implications under the reconciliation process. Recent changes to the House bill — such as giving states power to decide whether to keep or jettison a set of health benefits that the ACA requires many health plans to include — could be an obstacle. If and when the bill gets past the parliamentarian, many senators are wary especially of the changes the legislation would make to Medicaid.

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