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S. 191 (115th): Patient Freedom Act of 2017


Several Republican plans have been proposed for replacing the Affordable Care Act, also known as Obamacare, once that law is dismantled or repealed. S. 191, nicknamed the Patient Freedom Act, has been introduced by Sen. Bill Cassidy (R-LA), a licensed medical doctor.

What the bill does

The legislation aims to shift the question of repeal to states by allowing them to continue to use the ACA as is or move to state-specific plans that rely on health savings accounts and decreased financial support from the federal government. This bill is in keeping with the Republican belief that the federal government exerts too much control over states. The bill maintains some of the more popular parts of the ACA, contrary to some House Republicans’ calls for wholesale repeal, while eliminating or significantly reducing portions which Republicans find more objectionable.

Among the provisions eliminated include:

  • The “individual mandate” requiring all individuals not already covered by their employer to either purchase health insurance or pay a fine;
  • Employer requirements to provide health insurance to anybody working at least 30 hours per week or small businesses employing at least 50 workers;
  • Requirements of benefits for all plans regardless of a given customer’s needs and which may increase plan costs. (An infamous example is maternity coverage for women past child-bearing years.)

The bill maintains:

  • Existing rules allowing children to stay on their parents’ health insurance plans until age 26
  • Preventing denial of coverage based upon pre-existing conditions;
  • Prohibiting both annual and lifetime limits by health insurance companies.

From there, each state would have one of three choices: essentially re-adopt the ACA on a state level, create a new state-designed plan with federal assistance but less money than the ACA provided, or create a new state-designed plan with no federal assistance at all.

Who supports it

Supporters argue that the bill will lower federal expenditures and patients’ premiums, while giving individuals more options regarding their health insurance and doctors.

“The ACA has been in full effect for three years, yet nearly 30 million people still do not have health insurance coverage. Those who do have coverage are experiencing huge spikes in premium costs, deductibles, and co-pays,” cosponsor Sen. Susan Collins (R-ME) said in a press release.

“The [bill] will help ensure that more Americans have access to affordable health care that improves choice and helps restrain costs. With this legislation, we are placing a specific replacement proposal on the table for our colleagues to coalesce around, debate, and refine so that our efforts can move forward with no gap in coverage for those relying on the current system.”

Currently, statements of support come from the Senate sponsors, while advocacy and industry groups have yet to address this bill.

Who opposes it

Opponents argue the ACA (Obamacare) has been a historic step to cover the previously-uninsured and slow the rate of health care cost increases, and any step in the opposite direction would erase those hard-fought gains. They also worry that eliminating the individual mandate could cause health insurance companies to once again discriminate based on preexisting conditions, to keep costs down as a result of decreased revenues.

Those arguments are well-known, but more surprisingly, some opposition even comes from conservatives themselves. Christopher Jacobs, founder and CEO of the policy consulting organization Juniper Research Group, wrote for the right-leaning news outlet_ The Federalist_ an article titled “4 Ways the Patient Freedom Act Is Worse Than Obamacare.”

Jacobs claimed that the bill would expand taxpayer funding for abortions (by providing federal funding for states as a workaround to the ban on federally funding abortions), could increase total federal expenditures by increasing Medicaid funding even for states choosing not to expand the program, perpetuates government-mandated price controls, and creates a “big government” automatic enrollment program.

Odds of passage

It’s attracted four Senate cosponsors, all Republicans, and awaits a vote in the Senate Finance Committee. The bill was previously introduced in 2015, where it attracted nine Republican Senate cosponsors but never received a committee vote, despite Republicans controlling the chamber.

President Trump said he will reveal his administration’s own health care plan once his Secretary of Health and Human Services nominee Tom Price is confirmed (Price was confirmed earlier this month). The Administration’s plan may draw heavily on existing Republican proposals in this Congress, such as the Patient Freedom Act or others.

That’s assuming the Affordable Care Act is repealed at all. Some predict that the status quo will be maintained, or at the most some portions will be dismantled instead of outright repealed. The challenge to modifying the ACA is that in order to get insurance company buy-in for elimination of coverage of pre-existing conditions, the government has to find a way to guarantee or at least strongly encourage plan purchases by healthy people, thus the individual and employer mandates.

Last updated Feb 22, 2017. View all GovTrack summaries.

The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Jan 23, 2017.


Patient Freedom Act of 2017

This bill provides states with three options regarding title I (provisions on health insurance reform, exchanges, and subsidies) of the Patient Protection and Affordable Care Act (PPACA): (1) continue implementing PPACA, with a limit on total premium and cost sharing subsidies provided in the state; (2) waive the requirements of title I of PPACA, with specified exceptions; or (3) the second option plus implementation of a Roth health savings account (HSA) deposit system. Only residents of states continuing to implement PPACA are eligible for PPACA premium subsidies.

The bill amends the Internal Revenue Code to set forth provisions regarding Roth HSAs, which have annual contribution limits and are not subject to taxes. Contributions to Roth HSAs are not tax deductible.

In states implementing a Roth HSA deposit system, residents who are enrolled in health insurance coverage that meets state standards receive monthly deposits in their Roth HSAs. States that administer deposits are entitled to payments from the Department of Health and Human Services for population health initiatives.

States with a Roth HSA deposit system must penalize residents who have a break in health coverage and may enroll residents in a default high deductible health plan that is continually available for enrollment.

Contributions may no longer be made to non-Roth HSAs.

HSAs and Roth HSAs may be used to pay monthly or prepaid amounts for physician services. These services are not considered to be health insurance.

This bill amends SSAct title XVIII (Medicare) to require participating hospitals to limit costs to individuals for uncovered emergency medical care.

Persons providing medical care must post prices.