People are still dissecting and deciding where they come down in response to the recently proposed legislation to repeal and replace the Affordable Care Act. Yesterday, two of the largest groups in the American healthcare business advised lawmakers that they are not thrilled with what they’ve seen so far.

The American Hospital Association and the American Medical Association each released copies of letters they sent to members of Congress addressing their concerns with the bills — collectively the American Health Care Act (ACHA) — proposed by the House Ways and Means Committee and the House Committee on Energy and Commerce.

The AMA, which represents hundreds of thousands of physicians in the U.S., acknowledges in its letter [PDF] that the Affordable Care Act has problems that “must be addressed,” but that the AMA “cannot support the AHCA as drafted because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations.”

One issue raised in the AMA letter is the GOP plan to help Americans afford insurance through tax credits. The organization notes that it supports this idea in general, so long as the actual credits are “sufficient to enable one to afford quality coverage.”

The proposed plan would provide individual tax credits of between $2,000 to $4,000, coming out to between $167 and $333 per month, which may not be enough for some people to afford coverage on their own. Additionally, there is a maximum of $14,000 per family, regardless of the number of family members. The tax credits also get increasingly smaller for individuals who earn more than $75,000 per year ($150,000 for families).

The AMA takes particular issue with the GOP’s decision to tie tax credit levels to age instead of need, with taxpayers under 30 years old eligible for the lowest levels while those over the age of 60 are eligible for the largest credits.

“We believe that credits should be inversely related to an individual’s income,” writes the AMA. “This structure provides the greatest chance that those of the least means are able to purchase coverage. We believe credits inversely related to income, rather than age as proposed in the committee’s legislation, not only result in greater numbers of people insured but are a more efficient use of tax-payer resources.”

The doctors’ group also questions the plan to scale back the Affordable Care Act’s expansion of Medicaid programs, which the AMA says “has proven highly successful in providing coverage for lower income individuals.”

Then there’s the matter of the Prevention and Public Health Fund, which currently provides funding to a variety of public health concerns, covering everything from diabetes to Alzheimer’s to anti-smoking efforts. The GOP proposal would halt Congressional financial support of this initiative — a mistake, according to the AMA.

“The Public Health and Prevention Fund has supported many critical projects, including investments in immunization, childhood lead poisoning, and health-care associated infections,” explains the letter. “Currently the fund comprises approximately 12 percent of the budget of the Centers for Disease Control and Prevention and should be preserved.”

In its letter to all members of Congress [PDF], the American Hospital Association — which represents some 5,000 healthcare facilities — politely raises a big question: How many people will be eligible for coverage?

Neither of the AHCA bills put forth by these committees included estimates from the Congressional Budget Office about the number of people that would be affected. Earlier this year, the CBO released a detailed analysis of a previous repeal-and-replace bill and estimated that there would be around 18 million additional people without insurance after the first year.

The AHA says it is unable to support a healthcare reform bill that doesn’t address the impact on coverage numbers.

“Lacking that level of analysis and needed transparency, we urge that Congress should wait until an estimate is available before proceeding with formal consideration,” says the letter.

Like the AMA, the hospital group also raises concerns about paring back of Medicaid expansion, arguing that it could “have the effect of making significant reductions in a program that provides services to our most vulnerable populations.”

The Affordable Care Act slashed “disproportionate share payments” — federal funds provided to certain hospitals to offset some of the cost of caring for patients who can not afford to pay. The idea was that, because the law now requires most people to have some sort of health insurance, hospitals will be treating more paying patients and fewer uninsured patients.

However, as the AHA addressed in a letter sent to the White House earlier this year, repeal of this individual coverage requirement — coupled with scaling back of Medicaid coverage — would put hospitals back on the hook for patients who can no longer obtain insurance.

In the letter sent yesterday, the AHA reiterates that these billions of dollars in federal support will need to be restored in order for hospitals to continue treating the uninsured and underinsured.

“We ask Congress to protect our patients, and find ways to maintain coverage for as many Americans as possible,” concludes the AHA. “We look forward to continuing to work with the Congress and the Administration on ACA reform, but we cannot support The American Health Care Act in its current form.”

The two pieces of legislation now enter into the markup process, where the finer points of the bill will be hammered out in committee before going to the full House for a vote.

It’s important to note that the repeal and replace bills are not traditional pieces of legislation, but are instead parts of a larger budget resolution. That means that, unlike your typical bill, they can be passed by a simple majority in the Senate instead of requiring support from 60 senators.

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