By Jennifer Taylor, Deputy Director, Federal Affairs
Yesterday, Senate Republican Leadership released an updated version of the Better Care Reconciliation Act (BCRA), their proposal to repeal and replace the Affordable Care Act. We laid out the details of the original Senate draft in our previous analysis, so we won’t go through all of the bill’s provisions here. Instead we wanted to highlight key changes in the latest version, and give you an idea of what to expect in the days ahead.
What Stayed the Same?
The updated version of the bill is largely similar to the draft released by the Senate in June. Of primary concern to health centers, the bill continues to end the Medicaid expansion and to dramatically alter the underlying Medicaid program by shifting it to a per capita cap financing structure. The Congressional Budget Office (CBO) estimates the original draft of the Senate bill would cut $772 billion from Medicaid and result in 15 million fewer people being enrolled in the program over the next 10 years. A new CBO score of this revised draft is expected early next week, but given that only minor tweaks were made to the Medicaid provisions, we assume those numbers will not change significantly.
Like the earlier draft (and the House-passed legislation) the bill still repeals the individual mandate. After 2019, it continues to repeal the ACA’s subsidies for co-pays, deductibles and other cost-sharing (so called cost-sharing reduction, or CSRs). Like the earlier draft, it retains the ACA’s subsidies to help individuals below 350% of the Federal Poverty Level (FPL) pay their insurance premiums, but pins the value of those subsidies to plans with less coverage and higher deductibles.
A handful of key changes were made to the bill in an attempt to address concerns voiced by Senators in response to the original draft, including:
- An additional $70 billion in funding added to a stabilization fund that could be used in a variety of ways, including state-based reforms regarding cost-sharing and use of Health Savings Accounts (HSAs)
- Allowing people to use Health Savings Accounts (HSAs) to pay health insurance premiums
- An additional $45 billion in grant funding to combat the opioid epidemic
- Allowing insurance companies to sell lower-premium/higher-deductible health insurance plans (as well as catastrophic coverage plans) in the individual insurance market, and to make them eligible for federal tax credit assistance
- A new fund to make payments to specified health insurance issuers for the costs of covering high risk individuals
- Minor changes to Medicaid provisions, including a revised Disproportionate Share Hospital (DSH) payment calculation; waiver authorization for states wanting to utilize home and community-based services for aged, blind, and disabled populations; an expanded option for states to include Medicaid expansion populations within block grants; and a temporary and limited exclusion of declared public health emergencies from proposed per capita cap limits.
- The bill delays the repeal of a handful of tax provisions from the ACA – the tax on investment income and the tax on insurance company executives.
In the next few days we will hear much more from Senators about whether or not the changes that have been proposed alleviate their specific concerns. Senate Leadership still intends to bring the bill up for a vote next week, though at least two Senators – Senator Susan Collins (R-ME) and Senator Rand Paul (R-KY) – have already declared their intent to vote against the Senate, starting debate on the bill. With all Democrats remaining opposed to the bill, Republicans cannot afford to lose even one additional vote or they won’t be able to move forward next week as planned.
In the meantime, health center advocates should continue to make their voices heard. Visit the Health Center Advocacy Network to weigh in with your Senators now. And if you have any questions, don’t hesitate to reach out to us at firstname.lastname@example.org.