As Congress Returns, Leaks, Rumors and Disagreements Dominate the ACA Debate

By Oliver Spurgeon and John Sawyer, NACHC Federal Affairs Team

Normally, a Congressional recess, where Members travel home to hold meetings with constituents in their districts, is a relatively quiet time for those of us in Washington. Staffers on the Hill don jeans in lieu of suits, and may pull back to working 8 or 10-hour days, rather than the typical 12+. For those of us following the health care debate in Washington closely, however, last week’s recess was anything but boring.

Friday morning, a leaked and dated draft of House Republicans’ budget reconciliation bill ‒ their initial ideas to repeal the Affordable Care Act (ACA) ‒ landed in inboxes across Washington as lobbyists and staffers were finishing their morning coffee. Judging by the crooked pages, missing page numbers, and numerous pen scribbles throughout the document, the effort is far from complete. Yet after almost 7 years of Congressional pledges to “repeal and replace” the Affordable Care Act (ACA), and roughly two months of relative inaction on Capitol Hill, the draft bill does provide more detailed insight into thinking amongst House leaders than had previously been available. The bill would roll back the ACA Medicaid expansion, replace the ACA premium subsidies (which are determined based on income) with tax credits based on age, make funds available to States to create high-risk pools or other “innovations,” and would attempt a major structural change to the Medicaid program – shifting away from the current entitlement structure to one where federal contributions are capped. A good summary of the provisions is available on Health Affairs’ blog here.

Yet the leaked draft was also quite dated, with a date-stamp indicating it was current thinking as of February 10th. Two weeks is a lifetime in politics, as they say – and the same goes for complex legislation. This rule of thumb definitely applies as bills get more complex, and can often result in first drafts and final products that are miles apart in terms of content and outcomes. The 2009-2010 effort to pass the ACA is a testament to that rule. Remember, after 15 months of debate ‒ passing a major bill through Congress was and still is a slow and tedious process ‒ the House’s initial draft of the ACA and the version signed into law looked nothing alike.

Friday also marked the beginning of the annual meeting of the National Governors Association here in Washington. Considering how intertwined the ACA is with state-level policy and politics, the nation’s Governors are expected to be among the most important voices as Congress considers health policy this year. So what emerged from the Governors discussions? More disagreements, even among the majority Republican governors, and more leaks.

Medicaid seems to be the main flashpoint, understandably, for the governors. Specifically, documents leaked to and subsequent reports suggest that Republican governors are still in very different places from one another when it comes to the Medicaid expansion question, and the details of proposed structural changes like a per-capita cap or block grant. Disagreement among governors tends to make especially Senators very hesitant, since mostly Senators don’t like to go against their own state’s governor – especially when they come from the same party.

On the eve of Congress’ return, more disagreements came into the open. On Monday night, Rep. Mark Walker (R-NC), Chair of the conservative House Republican Study Committee, and Rep. Mark Meadows (R-NC), Chair of the even more conservative House Freedom Caucus, both announced that they could not support the House bill if it resembles the leaked draft. Together, Walker and Meadows represent well over 100 members of the House Republican Conference. So, without Democratic support, no bill is likely to pass if either of these groups is opposed, much less if both of them are.

All of this taken together suggests that Congress is actually quite a bit further from resolving the “repeal/replace” issue than anyone initially thought. If you need further proof that Congress remains in the starting blocks on healthcare reform, just look at of all the organizations still providing ideas to Republicans and Democrats in the House and Senate. Doctors and hospitals continue to beat the drum of patient access, and insurers, drugmakers and governors are all amongst those visiting with the Trump administration over the last couple of weeks. And of course, health centers are still weighing in with everyone involved in this process to highlight and promote the value and impact of our national system of care.

Bottom line? While we need all advocates to stay engaged in the debate (check out our fabulous new advocacy website, for any number of ways to do so), it’s also vital that we stay focused on the health center message, and that we not bet the farm on leaks, rumors, or innuendo. In the meantime, the Federal Affairs team here at NACHC will continue to monitor developments on the Hill, and ensure that the voices of health centers are represented at the negotiating table. Continue to follow Health Centers on the Hill for future updates, plan to join us for the next monthly Policy and Advocacy Webinar on March 21st, and most important, come make the case in person during the 2017 NACHC Policy and Issues Forum.

If you have any additional questions, comments, or concerns, or just want to learn a little more about buzzwords like “per capita caps” and “block grants,” please feel free to contact us at


Senate takes first (of many) steps toward ACA repeal

Early this morning, after a 7-hour marathon of votes on amendments, the U.S. Senate approved S.Con.Res 3, the Budget Resolution for the current federal fiscal year, FY2017, on a vote of 51-48. While Senate leadership referred to the bill as the “Obamacare Repeal Resolution,” it’s important for advocates to know that this bill itself does not make any changes to the law. That said, when (as is expected by the end of the week) the House passes an identical resolution, it puts Congress one step closer to eventual consideration of ACA repeal legislation.

So why does the process start here? As we noted in a blog post last week, this first step is what allows the Congress to use a process called Budget Reconciliation, a fast-track procedure that allows certain kinds of bills to pass the Senate with a simple majority of 51 votes, rather than the 60 votes usually necessary to overcome a Senate filibuster. The next step will be for both House and Senate to draft and debate the actual repeal legislation, find common ground enough to pass the bill through both chambers, and send it to soon-to-be-President Donald Trump for his signature or veto.

Increasingly, however, the strategy around ACA repeal is beginning to shift. A greater and greater number of Members, especially in the Senate, are expressing concern about the potential for passing a repeal bill without a clear plan in place for what a replacement for the ACA would look like. Health Center advocates heard that concern repeatedly in meetings this week, as our State Legislative Coordinators and certain Key Contacts flew in to DC and held meetings with Members on the Hill. In his press conference this week, the President-elect seemed to endorse the idea that a replacement must come simultaneously, saying:

“It will be essentially simultaneously. It will be various segments, you understand, but will most likely be on the same day or the same week but probably the same day. Could be the same hour. We’re going to do repeal and replace. Very complicated stuff.”

So while one step has been taken, many more remain. We’ll be keeping track here at Health Centers on the Hill, and reporting regularly. In the meantime, make sure you are making your voice heard with the new Congress and weighing in about the importance of health centers in 2017!



Understanding the Potential Timeline for ACA “Repeal and Replace”

By Michaela Keller, NACHC Federal Affairs Staff

Now that the 115th Congress is underway, it is expected that Republicans will move ahead quickly to fulfill one of their top campaign promises – repeal of the Affordable Care Act. With a majority in both the House and Senate, Republicans are charting a course to send a repeal bill to the President-Elect, possibly within the next two months. However, a repeal of this kind is easier said than done and major obstacles – including the lack of consensus on an alternative, the desire to maintain certain aspects of the law and the continued opposition and concern being expressed by a number of health care stakeholders – may quickly change the course of this plan. Understanding the steps involved in Congressional process will help advocates better track the debate. Here are a few of the major actions related to a repeal plan that we are likely to see in Congress over the next couple of weeks and months: 

Senate Budget Resolution Vote

The Senate is planning to vote in early January on a budget resolution that will include instructions to repeal large parts of the Affordable Care Act through reconciliation. As you may recall, reconciliation is the process by which legislation in the Senate can pass with a simple majority (51 votes) rather than 60 votes as required for major pieces of legislation; however, any legislation passed through reconciliation must only involve budget-related changes, meaning that any changes that do not have a fiscal impact cannot be included.

The budget resolution process in the Senate will likely take several days and will culminate in what many call a “vote-a-rama” or a series of several votes that will take place over several hours and potentially stretch long though the day and night.

House Budget Resolution Vote

Once the Senate passes the budget resolution with reconciliation instructions, the action shifts to the House, which will move quickly take up a vote to pass the resolution. Predictions are that this vote will occur prior to Inauguration Day on January 20th.

It is important to note that while the budget resolution is the first step in the process of repealing the Affordable Care Act, nothing happens to the ACA just yet – it merely sets up Congress for the next step in the process, which is to introduce a repeal bill.

Repeal Bill Moves Forward

The process of introducing repeal legislation will begin in the House, given that it must comply will the rules of reconciliation to include only budget-related changes and any bills that have an impact on revenue must originate in the House. The House Committees with jurisdiction over health care, including Energy and Commerce and Ways and Means, will start this process in the House by marking up legislation that they will then send to the House Budget Committee, which will craft a repeal bill.

House Repeal Bill Vote

The House Ways and Means repeal bill will eventually go to the House floor to be voted on. The expectation is that the House repeal bill will look similar to the repeal bill that was passed by both the House and Senate but vetoed by President Obama in 2015. While that bill did not fully repeal the ACA, it did repeal many of its major tenets, including Medicaid expansion, premium tax credits, and the individual and employer mandates, among other provisions (check out our blog post on that bill here).

Senate Repeal Bill Vote

Once the House votes on its repeal bill, it will go to the Senate. It’s not clear at this point whether the bill will go through the Senate Committees with jurisdiction or go right to the Senate floor for a vote. Once a bill comes to the floor, there will likely be extensive debate, with Republicans looking to potentially include additional repeal provisions from the ACA and Democrats looking to force several votes on specific provisions included in the bill.

Conference Committee/ House Vote

If the Senate votes on passing a bill that is different than the House passed bill, either a conference committee will be formed to deal with the changes or the House will vote on the Senate passed bill. It is anticipated that this process will take place rather quickly.

Repeal Bill Signed into Law

By this point, the President-Elect will be sworn into office and the final repeal bill that Congress agrees upon will be sent to the President’s desk to be signed into law.

While we will likely continue to hear talk about a “replace” plan while the repeal bill is debated, it is much less clear when, and in what form, we will see what Congress’s plan for “replace” will include. As you’ve heard before and will continue to hear, fundamental changes to the health care system will be debated over the coming weeks, months and potentially years – changes that could greatly impact the work of health centers and impact the patients we serve. None of these actions is a foregone conclusion, but advocates need to be informed and engaged. That’s why we’ll be keeping a close eye on how that debate unfolds and will continue to keep you updated as this process moves along.

Questions? Email us, at

2016 on the Hill for Health Centers

It’s been a big year on Capitol Hill for our nation’s health centers. One may have thought that, following an historic victory in 2015 getting a 2-year extension of funding, this “off year” would be a time for resting on our laurels and rebuilding for the fights to come in 2017. While certainly plenty of time and energy has been devoted to looking ahead to the big questions on the table next year, this year itself has been filled with important policy debates, record-breaking advocacy, and some important legislative wins for health centers.

Early in the year, health center advocates descended on Capitol Hill for the 2016 Policy and Issues forum in Washington, DC, where NACHC highlighted health center innovation in a well-attended Congressional Briefing, and put the spotlight on the workforce challenges being faced at health centers with the release of a new research report. Health Center advocates succeeded in breaking records on our annual appropriations letters – with over 300 House Members signing onto the Bilirakis-Green letter in the House and over 60 Senators signing onto the Stabenow-Wicker letter in the Senate. With that many members on record, both House and Senate appropriations committees passed FY2017 legislation keeping health center funding level, in line with NACHC’s official request.

Following action in those Committees, the appropriations process stalled out over larger political conflicts (and indeed, is technically still underway – the government is operating under a stop-gap “continuing resolution” until next April). But even as work on the funding issues slowed, health centers were at the center of several other debates and conversations on health policy on the Hill.

Efforts to fund a response to the Zika virus, especially in Puerto Rico and the other U.S. territories, finally were passed into law in late September after months of back and forth on Capitol Hill. The final package contained $40 million for health centers in Puerto Rico and the territories, which was allocated last week.

The opioid epidemic that has been raging throughout much of the nation moved Congress to take action this year, culminating in the eventual passage of the Comprehensive Addiction and Recovery Act (CARA) which outlines a number of new measures to combat the epidemic. Health Centers have been on the front lines of that fight for years, and last year, 271 health centers were funded specifically to expand and enhance their substance use disorder treatment services.

Alongside the debate over substance use disorder policy, Congress spent a lot of time this year looking at the mental health system. Bills were passed in the House and Senate, and eventually reconciled into a larger package that passed at the end of the year. While advocates were not successful in securing a requirement for same-day billing for mental health visits under Medicaid (a top – but expensive – priority for health centers), the bill did contain several provisions of note. In particular, it included both a long-sought provision expanding health centers FTCA Medical liability coverage, or FTCA coverage, to volunteer providers, as well as a provision allowing health centers to assign patients to Accountable Care Organizations (ACOs) at the FQHC level. More on both of those provisions and what they mean for health centers here.

Even with all the different pieces on the chess board in 2016, we’ve spent an equal or greater amount of time (especially since the November elections) focused on what lies ahead in 2017. Big issues will need to be dealt with, and could have enormous implications for health centers and their patients. In particular, the two-year extension of funding mentioned earlier is up this fall, meaning a loss of 70% of federal grant funds to health centers (and elimination of the National Health Service Corps and Teaching Health Centers programs) if Congress fails to take action. Equally critical, the Medicaid program will be very much “on the table” given the expansion under the ACA and the desire on the part of many in Congress to fundamentally restructure the program.

More than 1,000 advocates joined our team for a Policy and Advocacy Webinar last week (missed it? Here’s the recording), during which we reviewed the election, some of the new faces in DC, our top priorities and the outlook for 2017. This is now something we’ll be doing on a monthly basis moving forward. Here’s the link to register for the next one, which will be at 3:30 PM EST on January 18th. As we enter a complex and uncertain year, these webinars, as well as our new “Making the Case” Resource Hub website, are the best ways to stay in touch and stay engaged.

From our team to yours, happy holidays and happy new year. Rest up, we’re going to have our hands full in the new year!







Mental Health



Our Analysis: What 2017 Could Hold for Health Centers

With the 114th Congress scheduled to wrap up by the end of this week (with a few key victories for health centers along the way), we here on the NACHC Policy and Advocacy team are nearly 100% focused on preparing for 2017, which will be a pivotal year for health centers unlike any we’ve seen in some time. Every health center advocate heard directly this morning from NACHC President and CEO Tom Van Coverden about the 4 steps advocates can take NOW to engage and be ready for many of the state and federal legislative debates to come.

In addition to those steps, many of you have asked us for a more detailed analysis of the elections, the new faces in key areas of influence, and of what’s “on the table” and what’s off in Congress next year. That memo is linked below:

NACHC Election 2017 Outlook Memo 12.28.16 (updated 12.28.16)

One thing that you’ll see noted in the memo is that our staff will be hosting monthly Policy and Advocacy Webinar Briefings between now and the 2017 Policy and Issues Forum in late March. The goal of these briefings is to keep all health center advocates up to date on the latest developments, our “asks” and arguments, and resources to help make the case in the year ahead. The first webinar briefing will take place next Wednesday, December 14th, at 3:30 PM Eastern Time. Click here to register.

The environment is changing rapidly here in DC, and our goal is to keep you up to speed. As always, don’t hesitate reach out to our staff at with any questions, ideas, or report-backs from recent conversations with Members of Congress.