MacArthur Amendment: Myth vs. Fact

Courtesy of the Energy and Commerce Committee and the Office of Rep. Tom MacArthur:

1. Myth: This Amendment does not cover pre-existing conditions.

FACT: The MacArthur Amendment explicitly maintains protections for pre-existing conditions. NO STATE, under ANY circumstances, may ever obtain a waiver for guaranteed issue of coverage, guaranteed renewability of coverage, or the prohibition on denying coverage due to pre-existing conditions. The amendment specifically clarifies that its provisions cannot be construed as allowing insurers to limit coverage for those with pre-existing conditions.  All of these protections will remain the law.

2. Myth: This Amendment will price those with pre-existing conditions out of the market, making health care unaffordable for them.

FACT: The amendment’s limited waiver for health rating requires states to set up a program for high-risk individuals or premium stabilization, or to participate in the federal invisible risk sharing program. No state may obtain a waiver for health status unless it has taken these efforts to protect those who might be affected. In states with a waiver, individuals who maintain continuous coverage could not be rated based on health status.

3. Myth: High-risk pools have traditionally been underfunded by states and the federal government, resulting in poor coverage and high costs for those who need insurance the most.  

FACT: The AHCA sets aside $100 billion over ten years to help states with high-risk pools and other innovations. It sets aside an additional $15 billion specifically for maternity care, mental health care, and substance abuse treatment. And it sets aside an ADDITIONAL $15 billion for a federal invisible risk-sharing program -- another innovative way to help people access affordable coverage.    

  • The Upton-Long amendment further strengthens the American Health Care Act’s (AHCA) protections for Americans with pre-existing conditions. Specifically, the Upton-Long amendment would provide an additional $8 billion in resources over 5 years to those with pre-existing conditions.

4. Myth: Under this amendment, States do not have to cover essential health benefits.

FACT: This amendment ensures essential health benefits are the federal law of the land and maintains other important protections.

  • States have the option to obtain a waiver regarding federal essential health benefits, but the state must publicly attest its purpose for doing so (to reduce the cost of healthcare coverage, increase the number of people with healthcare coverage, etc.) and it must specify the benefits it will require instead of the federal standard.
  • NO STATE, under ANY circumstances, may ever obtain a waiver for pre-existing condition protection, prohibition on gender discrimination, for guaranteed issue and renewability, or for the right of dependents to stay on a family plan up to age 26.

5. Myth: 129 Million Americans have pre-existing conditions and could be denied coverage.  

FACT: This legislation addresses the 7% of Americans on the individual market, and those in the small group market.  Most Americans with employer-provided coverage or government coverage (Medicare, Medicaid, Tricare, VA benefits, etc.) would not be affected.  Again, this amendment would not allow any state to deny coverage to those with pre-existing conditions, and would require the extensive protections described above for those with riskier health profiles. 

6. Myth: Members of Congress and their staff are exempt from these healthcare changes

FACT: Members of Congress and congressional staff will be treated the same way as any other citizen.  Republicans made sure of this by passing H.R. 2192 to ensure that the American Health Care Act (AHCA) and its amendments apply equally to everyone.