The skinny on partial repeal: It would unravel individual market

Andis Robeznieks , Senior News Writer

There was a flurry of activity in the Senate featuring the dramatic return of Sen. John McCain, R-Arizona, days after being diagnosed with glioblastoma, a tie-breaking vote cast by Vice President Mike Pence, and much speculation over what will happen next.

A likely scenario includes the introduction of a “skinny repeal” that would eliminate some the mandates and taxes included in the Affordable Care Act (ACA). Last year, the Congressional Budget Office (CBO) projected repealing the individual insurance mandate would result in some 15 million more people being uninsured by 2026. This includes some 2 million who would lose employment-based coverage, 6 million fewer buying insurance from the insurance exchange marketplace, and 7 million fewer covered by Medicaid.

The AMA has asked senators to consider the impact proposed legislation would have on the health of all Americans. The Association has maintained that Senate efforts must not increase the number of Americans without health insurance, further weaken the individual insurance market, undermine critical safety net programs, or make it harder for low- and moderate-income Americans to obtain quality, affordable health insurance.

“To date, the amendments proposed to repeal or replace the Affordable Care Act fail to meet these basic requirements and would harm vulnerable patients in every state,” said AMA President David O. Barbe, MD, MHA, adding that a potential partial repeal would be no different.

“There has been considerable speculation regarding a so-called ‘skinny package’ that would primarily eliminate penalties related to the individual and employer mandates and provide tax cuts to device manufactures and the health insurance industry,” Dr. Barbe explained. “Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address. Instead, it leads to adverse selection that would increase premiums and destabilize the individual market.”

The parliamentary procedures being used to advance ACA-repeal efforts are getting as much attention as the content of the legislation. It began Tuesday with a vote on the motion to proceed . All 48 Democrats voted against it, as did two Republicans—Susan Collins of Maine and Lisa Murkowski of Alaska—creating a 50–50 deadlock which was broken by Pence’s vote.

Senators were to then consider a revised version of the Senate leadership’s Better Care Reconciliation Act (BCRA), which included amendments introduced by Sens. Ted Cruz, R-Texas, and Rob Portman, R-Ohio. That measure was ruled out of order after a vote to waive points of order failed by a 43–57 vote that included nine GOP senators voting against it.

On Wednesday, Senators debated an amendment to repeal significant portions of the ACA, as allowed by Senate Budget Act reconciliation procedures. The measure under consideration reflected the text of the Obamacare Repeal Reconciliation Act, which the CBO projected would result in 32 million more uninsured Americans by 2026 compared with current law. The amendment was defeated 45-55 with seven Republicans joining all Democrats in opposition.

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After casting his “yea” vote on the motion to proceed, McCain then called for bipartisan solutions.

Dr. Barbe issued a similar call.

“We again urge the Senate to engage in a bipartisan process—through regular order—to address the shortcomings of the Affordable Care Act and achieve the goal of providing access to quality, affordable health care coverage to more Americans,” said Dr. Barbe, a board-certified family physician from Mountain Grove, Missouri.

The AMA has opposed previous versions of BCRA, based largely on the projected impact on the number of Americans who will become uninsured and reduced federal support for Medicaid. Direct written and personal communications with members of Congress represent one component of a broad-based advocacy campaign that the AMA has been pursuing throughout 2017.

Physicians and patients who want to engage in the advocacy campaign to preserve access to affordable and meaningful health insurance coverage are encouraged to visit the AMA's campaign website, at The site explores the AMA's health reform objectives in depth and provides resource documents, patient profiles and grassroots action links to facilitate communications with their Senators.

Read more about the AMA's comprehensive vision for health-system reform, refined over more than two decades by the AMA House of Delegates, which is composed of representatives of more than 190 state and national specialty medical associations. Or explore the AMA Wire® special series, “Envisioning Health Reform.”