This story has been translated from Spanish and edited from its original version for clarity and length.

The future of the American health care system is in flux, and advocacy groups are looking to either persuade or punish congressional Republicans regarding their votes.

The House of Representatives voted by a slim 217-213 margin on May 4 to approve a new version of the Republican-backed bill known as the American Health Care Law (AHCA), which seeks to overhaul the existing Affordable Care Act (ACA) and scale back Medicaid coverage that was expanded under President Barack Obama. That vote has awakened a new backlash against lawmakers who voted for the bill, including a bilingual ad campaign against Nevada Republican Congressman Mark Amodei.

Amodei explains his support

Amodei noted in a recent interview with The Nevada Independent that he has said all along he was not voting for the bill if people would lose insurance they got through the ACA Medicaid expansion or if the state could lose its reimbursement from the federal government, which could create a shortfall of as much as a quarter of a billion dollars in 36 months.

Amodei said that in the course of talking with leadership and representatives of the Centers for Medicare and Medicaid Services (CMS), they identified language that was in the bill that said any Nevadan who has enrolled in the expanded Medicaid program from its inception in 2014 through the end of 2019 is free to stay in the program so long as their income does not exceed 138 percent of the national poverty level.

“And so what I told them was Seema Verma, who’s the lady who runs the Medicare/Medicaid section now in HHS, called the people in Nevada that ran Medicaid and said, ‘We think your interpretation of this language, either you didn’t see the language or we disagree with the interpretation, we will continue to let people who are signed up on Medicaid under the expansion continue on so long as they don’t make over 138 percent of poverty or if they don’t voluntarily elect to get off it if they get a job and they want to take their employer plan or something like that.’”  

While Amodei had publicly said earlier that he couldn’t vote for the AHCA, he said he was convinced to switch to a “yes” just before the vote over the Medicaid language.

“Now the change in this language was this: under the existing Affordable Care Act, you could get off of Medicaid and go back on it as much as you want it, and the change in it was this: it says, ‘Hey, once you make too much money or once you voluntarily elect to go to a private plan or an employer plan, you can’t come back on, but if you don’t do either one of those things, you can stay until you’re Medicare eligible at age 65 and then transition into that.’”  

That was enough to convince him.

“I decided to change my vote when we analyzed this language through CMS and Seema Verma and Tom Price, the secretary of HHS. Coordinated their reading with the folks in Nevada and said, ‘Okay, I said I won’t support it if these two things happen.  They’re not going to happen, so I’ll support it.’”

Amodei defended his vote and responded to the campaign.

“It’s America. People can say whatever they want on the issues,” Amodei said, adding that he also posted a written explanation to his Congressional website to express his primary focus in evaluating that proposal “was, and remains, the impacts on Nevada’s second largest insurance group – those on Medicaid (21%).”

Although the bill crossed the major hurdle of the House, where Republicans have a 238-193 majority, it has new challenges in the Senate, where Republicans have a slimmer 52-46 majority. Republicans including Nevada Sen. Dean Heller have said they don’t support the House bill and plan to develop their own version of an Obamacare repeal.

The ad

In the meantime, Save My Care, a group that has actively defended existing health care law, and the National Council of La Raza (NCLR) Action Fund, an organization that works to expand the influence and political power of the Latino community, have run  an opposition campaign in English and Spanish. The radio, mobile and social media ads criticize legislators, including Amodei, who voted in favor of AHCA.

“We do not want millions of people and millions of Latinos to lose their health care due to cuts in the ACA and Medicaid,” said Rafael Collazo, political director of the NCLR Action Fund. “This is a human and a civil right.”

A Spanish version of the radio ad targeting Amodei says 37,000 beneficiaries in the community will lose their health coverage under the AHCA, and invites people to call their representatives in Congress.

Collazo said that after Amodei "took his shameful vote," NCLR Action Fund decided to run the campaign to let Latino voters, especially those living in the district that Congressman Amodei represents in Northern Nevada, know the importance of the upcoming vote for AHCA in the Senate, and to communicate with Amodei to let him know their displeasure.

"We want to save health care for everyone in the Latino community," said Collazo. "Especially those who could potentially lose it if the bill becomes a law."

Collazo added that the campaign criticizing Amodei is expected to run for several weeks and then could turn its attention to Heller now that the bill repealing the ACA is in the hands of the Senate. Heller has expressed skepticism about the bill.

“I want to repeal Obamacare in a way that benefits Nevadans, but I think that the current bill falls short,” Heller said in a statement. “I will not support it in its current form in the Senate, and am confident that what the Senate considers and approves will be different from the House bill.”

Amodei said he did not agree with some of the statements in the ad campaign and that it completely ignores some issues.

“One is the state of health care right now in Nevada and elsewhere as such that we need to – and this is an important word – we need to start the process of fixing the things in the Affordable Care Act that need fixing,” he said. “And so while what the House passed isn’t going to be the final law, I don’t think we should wait until there’s total and complete unanimity to begin that process and throw things into the center for a while because I don’t believe that you will ever have complete unanimity on something like health care. You didn’t have it on the Affordable Care Act.  You certainly didn’t have it on the AHCA that passed out of the House.”

Health care reform, then and now

The Affordable Care Act was signed by President Barack Obama on March 23, 2010. It specifies, among other things, that Americans must have medical insurance or face fines, that companies may not exclude from coverage people who have pre-existing health conditions, and that the government will provide financial assistance in the form of subsidies or tax credits to help eligible people afford insurance.

A first version of AHCA, an effort to reverse the ACA, was presented by House Republicans on March 6, 2017. A report from the Congressional Budget Office indicated that it would eliminate health coverage for some 24 million Americans by 2026.

The bill was modified in the days that followed. Under the Republican proposal that eventually passed the House on May 4, states could choose which basic medical services will be mandatory, insurance companies may charge older people more than young people, and Medicaid would no longer be allowed to finance family planning services through clinics that provide abortion services, such as Planned Parenthood.

Among the other changes in AHCA, states can continue to add people to the Medicaid rolls who make up to 138 percent of the poverty level and are in the “expansion” category, and the federal government will continue to pay a large share of their expenses, but only until 2020. After that, states would have to pick up a significantly larger portion of the Medicaid costs if they choose to enroll new people whose income places them in the expansion category.

The federal government would continue to pay a relatively high share of the Medicaid costs for people in the expansion population if they enrolled before the end of 2019. But if a “grandfathered” Medicaid recipient’s income rises and they lose eligibility for more than a month, the federal government will never again reimburse the state at the attractive old rates, even if that person’s income drops again and they regain eligibility. That could mean a loss of benefits for low-income people or those whose income fluctuates, which is common among Medicaid recipients.

Another notable change, in comparison with current health care law, is that Americans would no longer be required to have medical insurance, although those who spend more than two months without coverage would face a penalty of up to 30 percent when trying to purchase a new plan.

Now that it’s in the Senate, AHCA will have to go through different stages before it can potentially come up for a vote and become a law. That includes complying with the requirements established by the Congressional Budget Office, which will estimate its economic impact, securing enough votes, and reconciling differences between the version of the proposals that were brought forward by the House and the Senate.

If both houses concur with the final content of the bill, it will be sent to President Donald Trump so it can be signed into law.

Nevada Independent reporter Michelle Rindels contributed to this story.

Feature photo: Republican Rep. Mark Amodei speaks at a town hall event in Carson City on Feb. 22, 2017. Photo by David Calvert.