What the MacArthur Amendment Means for People with Type 1 Diabetes

Republicans in the House of Representatives once again are trying to assemble the votes needed to pass repeal-and-replace legislation to the Affordable Care Act (ACA). And as with the previous effort in March, they have offered a proposal that would weaken coverage protection for those with preexisting conditions like Type 1 diabetes to win votes. According to an Axios report, GOP sources connected with Congress and the White House expect the health care bill, called the American Health Care Act (AHCA), to pass the House of Representatives this week.

What’s different this time?

Three words: the MacArthur amendment.

Introduced by Representative Tom MacArthur (R-New Jersey), this amendment to the previous bill would give states flexibility for determining:

  1. Whether people with preexisting conditions could be charged more than the average population for coverage
  2. What essential health benefits insurers must cover

The ACA set a minimum federal standard of essential health benefits and barred insurers from denying coverage or charging substantially more to those with preexisting conditions. An earlier version of the AHCA would have repealed those standards at a federal level.

How would it work?

States would apply for a waiver from federal health insurance standards to make these changes. State officials would have to attest, but not prove, that the changes they make would do one of the following: lower premiums on average, boost enrollment, stabilize the health insurance market in the state, or stabilize the price of premiums for people with preexisting conditions.

If granted a waiver, states could then allow insurers to charge more for those with preexisting conditions who let their coverage lapse, as long as insurers established a way to make sure people with preexisting conditions had access to coverage. They also could determine what benefits insurers need to cover for the conditions, and whether there would be a lifetime cap on benefits.

You can read more about what the bill does, or did before the amendment, here: “12 Takeaways About the House Plan to Replace Obamacare.”

What this might mean for people with diabetes

Republicans who back the bill say it will bring average premium costs down. The concern among patient advocates is that it would raise the cost of coverage and health care overall for people with preexisting conditions; this could price many Americans out of health insurance altogether, they argue. So far this amendment has been panned by JDRF, the American Medical Association, the American Hospital Association, and AARP, among other organizations.

According to a Health Affairs Blog post, the states which opt out of federal standards would likely need to set up high-risk pools for people with preexisting conditions, offer reinsurance (which is when insurers share the risk of coverage), or some combination of the two. In the past, high-risk pools were often subsidized by states, but they were underfunded. A California HealthLine report found that more than 30 states had high-risk pools around the time the ACA was passed; most had long waiting lists for financial assistance and caused spiraling costs for the states.

Read more: High-risk pools likely to return with ACA replacement plan.

The amendment also allows states granted waivers to pick and choose essential health benefits, including for services covered for a particular preexisting condition. People with a preexisting condition could have health insurance coverage that may not pay for some costs of the condition itself. A Commonwealth Fund report used an extreme example – technically an insurer might not cover chemotherapy for a person with cancer. An equally extreme nightmare scenario could be a person with Type 1 diabetes who has insurance that doesn’t cover the cost of insulin.

It’s important to note that these changes would only apply to those not offered insurance through an employer, which is a small percentage of those insured at the moment.

Why the new amendment?

Insurance coverage for preexisting conditions was a huge stumbling block to Republican efforts to repeal and replace the ACA. In late March, Republican leadership in the House of Representatives was forced to pull the original repeal-and-replace bill because it didn’t have enough votes to pass, despite a Republican majority.

In the last attempt at passage, the most conservative wing of Republicans in the House of Representatives wouldn’t agree to a bill unless it did away with preexisting conditions protection and the essential health benefits standard. However, when Republican leadership agreed in principle to those demands, they alienated too many moderate Republicans in the House. Republicans need to vote on a strict party line with few defectors to pass this repeal-and-replace law, as Democrats are expected to vote against the legislation.

The MacArthur amendment seems to be an attempt to thread the needle between the most conservative and the most moderate wings of the Republican party. It does this by essentially kicking the thorny questions of preexisting conditions and essential health benefits to the states. Depending on interpretation, more moderate Republicans can tell constituents they didn’t vote to strip these provisions from federal law while ultra-conservative Republicans can tell their constituents that they did.

Will it pass?

Good question. Depends on your meaning of “pass”.

According to a Politico report, House Republican leadership sees this as their last best chance to repeal the ACA, something the party has been vowing to do since 2010. Failure to do so could very well have long-term political fallout in the 2018 midterm elections; of course, passing repeal brings its own political problems.

If the legislation passes, it would then be taken up by the Senate. While the GOP also control the Senate, Republicans there are considered, as a body, more moderate than their House counterparts. Senate Republicans may balk at the MacArthur amendment and strip it from the legislation before trying to pass it. It would then be up to Senate and House Republicans to find common ground.

The White House and House Republican leaders sound confident about their vote count, but they sounded confident about their last attempt to pass the AHCA, as well. Whether the bill will get the votes needed to pass this time around is still up in the air.

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Craig Idlebrook is a past editor for Insulin Nation, Type 2 Nation, and Información Sobre Diabetes. He is now the community engagement and content manager for T1D Exchange.

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