BREAKING: House Vote Delayed and New CBO Estimate on AHCA (ACA Repeal Bill)

BREAKING: The House vote scheduled to happen today on the repeal of the Affordable Care Act was delayed... possibly until tomorrow morning. House Republicans could not get sufficient support to go forward with voting on the American Health Care Act. Since no Democrats are expected to vote for the bill, House Republicans can only spare 22 No votes... as of 1:30 PM EST today, they had 27 No votes. Update: Late Thursday, the president said if the bill does not pass today (Friday 3/24), the administration will "move on" to other matters like tax cuts and simply "let the ACA fail".

Also just released... The revised CBO report that now estimates insurance premiums would increase by 15-20% under the new GOP proposal (between 2018 and 2019), and $150 billion less would be saved against the federal deficit. Unchanged, the estimated 24 million who would still lose coverage. Not good. In fairness, it also says non-group premiums could be reduced by 10% by 2026 with an estimated 52 million uninsured.

The rush to pass this bill to a vote today seemed symbolic. Seven years ago today, the ACA was signed into law through a controversial reconciliation process. Since then, the House Republicans have attempted at least 60 times to repeal the landmark health care law. Today they have their chance and will take the first step to take the vote to the House, then the Senate. Here's an interesting visual aid to see which House Republicans are likely to vote for or against the bill.

Will it pass? I'll leave the speculation to the political pundits who track this closer than I do. Instead, I will share my observations of the debate and why we are still so divided:

Conservatives (especially the Freedom Caucus) think the bill does not do enough to erase any traces of Obamacare. They also feel obligated to fulfill their promises made during the 2016 election where many, including candidate Trump, ran on a clear repeal of the ACA. The problem is, many of their supporters liked the anti-Obamacare chant but like having coverage more. Many Trump supporters now understand how the ACA actually protects their care or understand how the proposed GOP proposal leaves them with less coverage or lost subsidies. We heard this at several town halls where many House Republicans felt the heat from their conservative constituents who demanded clear answers, like "How will this bill protect my coverage? or "Will I lose my Medicaid?". Many Republicans now fear losing their coverage, even in red states like Indiana where former Governor Pence expanded Medicaid. One former Trump supporter and grieving father, explains why he was disillusioned by the GOP repeal plan:

Consumers are still confused about health care and how the ACA works. I recently had an interesting conversation with an Uber driver in Los Angeles who was still uninsured, even though he qualified for an ACA subsidy. He said he was 41, healthy and did not see why he should bother with this "government scam". He said the noise around Obamacare was confusing and he just didn't want any part of it. When asked what he would do if he got seriously ill or hospitalized, he paused for a moment and quietly said, "I think the hospital will have to take me anyway, right?". Well, not exactly.

In a previous post, I shared my mother's tragic story of being uninsured and what can actually happen if you need critical life-saving care and do not have coverage. I was honored to share my story with KQED (PBS) radio yesterday (I will post later). My point is anyone can find themselves uninsured. Yet most people are not familiar with what this could really mean if they had a life-threatening health issue without coverage. The actual practices of hospital emergency rooms who receive uninsured patients via ambulance or walk-ins can be surprising. The federal law passed in 1986 called EMTALA (part of the more famous COBRA law) says a hospital can discharge a "stabilized" patient to the over-crowded waiting room of a county hospital, a park bench or bus stop. Think this only happens to undocumented and homeless people? Not true.

Hospitals are worried about the decline in insured patients they will have to treat. This unreimbursed care is a burdened shifted to those of us with private insurance, another reason why our health premiums will increase under the AHCA. The funding for the (DSH) disproportionate share hospitals was not restored under the AHCA and these "hospitals of last resort" are not prepared for the onslaught of newly uninsured expected to be added to their already full waiting rooms. Skeptical? Ask an ER doctor.

Fact checkers from ProPublica, Vox, Stat, Kaiser Health News and others are busier than ever, trying to sort fact from fiction and holding legislators on both sides accountable to their statements and estimates. Some misquotes were found to be innocent rounding errors and others are blatant disinformation and flat out lies. But how is the average consumer expected to know the difference?

What is also concerning is the obvious lack of understanding of how insurance or health care actually works within the legislators and the administration, the folks who write and vote on these bills. It's true. With CAHU and NAHU, I have personally met with dozens of legislators over the years at the California and U.S. Capitols and know that some have a much greater understanding than others. 15 members of the current Congress are actual physicians and should have an expert understanding of the complex health care system. Other legislators are credible experts in other areas like energy, defense or education, but completely uninformed about health care and insurance. In fairness, you cannot be expected to be an expert on all subjects. But ready or not, they all will vote (tonight or tomorrow) with whatever understanding they have collected. Some have made embarrassing statements like this one they later retracted. As I write this post, I am listening to the White House press conference and heard yet another example of this knowledge gap:

"Americans should have the freedom to buy the insurance they need. I don't know why a male should have to pay for maternity coverage." - Sean Spicer, WH Press Secretary

Answer: Insurance risk is pooled. The healthier subsidize the sicker risk. Throughout our lifetime, we will be sicker or healthier and will share the benefit of pooled risk. No individual is likely to need all of it, but we will all need some of it eventually. For example... As a single man, I paid for maternity coverage in my policy and later when I started a family benefited from this pooled risk. Now, at 52 and done having kids, I continue to pay for maternity as part of that same risk pool. That's how insurance works.

Even the late night comics understand this. Off-color humor and jokes aside, this other video clip from John Oliver (on HBO) explains it pretty well. (language warning)

Sorry if you did not like this video, but jokes aside, I think the message is pretty accurate. If you liked it, here's another humorous perspective on the ACA.

Last word... under our current system, the only way to immediately lower our health insurance premiums is to have less coverage or through premium subsidies (getting someone else to pay for it). All other promises to immediately deliver much better coverage for a fraction of the cost are simply untrue. Promises to drastically reduce our insurance premiums without controlling and reducing the runaway costs of actual health care are either misinformed or deliberately misleading. Truly lowering costs and premiums in a meaningful way is a herculean task that would take time (maybe a decade) and much more work than just nipping at the edges of insurance reform and regulation. But that's not what we are doing in this bill. As modified, the House bill would allow states to strip out essential health benefits as a way to lower insurance premiums. This could mean health plans might not cover maternity, could apply limits on mental health and other services, and calendar year or lifetime caps on how much your plan pays. Is that the better coverage we really were promised?

As a former insurance carrier executive who worked closely with actuaries and plan experts to design and price our health plans, I am confident eliminating or capping these "non-essential" benefits will not reduce insurance premiums as much as many hoped or expected. They are in for major disappointment. Having less coverage could also create a greater financial exposure for consumers to go bankrupt, even with insurance. Prior to the ACA, 60% of personal bankruptcies were related to medical expenses... sometimes with folks with "mini-med", limited-coverage plans often referred to as "junk policies". I think the axiom, "one man's junk is another man's treasure" applies here. There still is a robust market for people who will "roll the dice" and buy cheap health insurance coverage. It's not junk if you don't actually use it.

However this vote goes, I am proud to work with many insurance professionals, volunteers, media, consumer advocates, and health policy experts who tirelessly share their knowledge and the plain facts to help inform the public and policymakers and help us all see through the fog of political rhetoric. Since we like to quote our revered founding fathers, I will end this post by quoting John Adams (1770)...

I will enlarge no more on the evidence, but submit it to you, gentlemen— Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence...

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Michael Lujan is a volunteer advocate for the uninsured and small business. A health insurance industry veteran of thirty years, Michael is past president at CAHU.org and currently serves on the board of the California School-Based Health Alliance, a non-profit organization providing healthcare clinic at school locations. He is also a co-founder at Limelight Health, an insurance technology software startup based in San Francisco.

* Views and opinions my own