Health Care Legislation - Update
Features of Senate Bill. On Thursday, June 22, Senate Majority Leader Mitch McConnell (R-KY) released the long-awaited Senate version of legislation to "repeal and replace" the Affordable Care Act (ACA). The Senate bill, titled the "Better Care Reconciliation Act" (BCRA), follows the same basic structure as the House bill (called the "American Health Care Act" or AHCA), but it would provide somewhat more generous subsidies for the purchase of insurance and more slowly phase out enhanced federal payments for the ACA's Medicaid expansion (for childless adults). The Senate bill, like the House bill, would cap federal Medicaid funding to states, and would make deeper cuts that the House bill in Medicaid spending beginning in 2025. For an explanation of the bill see The Better Care Reconciliation Act: the Senate bill to repeal and replace Obamacare, explained, Vox. For an interactive tool to compare the ACA, the AHCA and BCRA, see Compare Proposals to Replace the Affordable Care Act, Kaiser Family Foundation.
Notably, the Senate bill makes it very easy for states to get waivers to change the set of "Essential Health Benefits" (EHBs) established under the ACA. Under current law (ACA), the prohibition on annual and lifetime limits is tied to the EHBs; a benefit that is not "essential" is not subject to the prohibition. Similarly, the caps on out-of-pocket expenditures are tied to EHBs. Thus, if a state chooses to change the EHBs for insurance plans sold in the state, consumers will lose some of the ACA's protections that are important to people with high medical expenses.
Carve-out for "blind and disabled" children. Notably, the Senate bill includes a "carve-out" from the Medicaid caps for "blind" and "disabled" children under age 19, which is intended to protect them from the significant cuts resulting from the caps. While the bill language does not specify how children would be identified as "blind" or "disabled" for the carve-out, Senate staff have indicated that the carve-out will apply to those children who are enrolled in Medicaid as a result of receiving SSI (Supplemental Security Income) benefits. This population is very limited - about 1.3 million -- compared to the number of children with special health care needs on Medicaid (about 5 to 6 million). Even if the carve-out covered a broader group of children, it would still not guarantee protection for these children because states will have discretion about how to use the total amount funds they receive from the federal government. Even if a state dedicated all extra carve-out funds to services for these children, the children would still be affected by any overall cuts in reimbursement to providers, which could reduce the number of providers taking Medicaid patients or the number of providers available in a community or region. In addition, states might still choose eliminate or reduce optional services, such as those provided through current waivers, and/or funds available to schools to provide services to children with IEPs.
CBO analysis. analysis of BCRA's impact on the federal budget and on the number of people with insurance coverage. The CBO concluded that enactment of the Senate bill would result in 15 million more people without insurance, relative to current law, by 2018. By 2026, there would be 22 million fewer people with insurance than under current law. The total cuts in federal Medicaid payments to states would be $772 billion over ten years, slightly less than under the House bill because the expansion would be phased out more slowly. But by 2036, Medicaid spending under the Senate bill would be 35% less than under current law. See New CBO Estimate: 22 Million More Uninsured Under Senate Republican Health Bill (Center on Budget and Policy Priorities, June 26, 2017). the Congressional Budget Office (CBO) released its
Process for passage of bill. Because BCRA is a "reconciliation" bill, special Senate rules apply. The "Motion to Proceed" to consideration of the bill can be approved by a simple majority rather than the 60 votes needed for other legislation. Once the Motion to Proceed is approved, the bill will be debated for 20 hours and then a "vote-a-rama" will take place, during which any number of amendments can be offered. Usually, each side will get one minute of debate for each amendment before a vote on it. It is important to note that an amendment "in the nature of a substitute" can be offered during this process. Such an amendment could re-write the whole bill, and Senators (not to mention the public) might have little or no chance to review it before a final vote on the bill occurs. It is unlikely that a substitute amendment would be offered unless the leadership knows that it can pass.
Since no Democrats are expected to support the bill, at least 50 of the 52 Republican Senators will have to support it to secure passage. Vice-President Pence can cast a tie-breaking vote to provide a majority. If the Senate approves the bill, it is expected that it will be sent straight to the House. If the House passes it, the bill could be sent to the president and signed into law. If the House does not approve the Senate's bill as-is, a House-Senate conference committee would be formed to work out a compromise. If both bills contain the Medicaid caps and cuts, then those provisions likely would remain in any final legislation. The conference committee product would need to be approved by both the House and Senate.
Public reaction. Medicaid advocates around the country have been working to educate Members of Congress and their staffs about the high likelihood that Medicaid caps would hurt all individuals on Medicaid. Numerous patient groups have issued statements opposing the legislation, particularly the Medicaid caps, as have health care providers and many religious leaders. Recent polls indicate that a majority of the public opposes the legislation. Nevertheless...
Outlook. President Trump and Republicans in Congressbelieve that the electorate gave them a have a mandate to repeal "Obamacare," so they are highly motivated to accomplish that goal. Although it will be difficult for Senator McConnell to satisfy both the far-right at the more moderate members of his caucus, he is considered to be skilled at crafting compromises, so may well figure out a way to get the votes needed to gain Senate passage, and that House Speaker Paul Ryan (R-WI) will be able to get the Senate bill through the House. The president is expected to sign the legislation. At this point, it is a very difficult to predict what will happen.
For more information about the legislation's impact, particularly on the Medicaid program, see:
Unpacking The Senate's Take On ACA Repeal And Replace (Health Affairs, June 22)
Medicaid Round Two: The Senate's Draft "Better Care Reconciliation Act Of 2017"(Health Affairs, June 24)
At Risk: Medicaid's Child-Focused Benefit Structure Known as EPSDT (Georgetown Center on Children and Families, June 2017)
Factors Affecting States' Ability to Respond to Federal Medicaid Cuts and Caps: Which States Are Most At Risk? (Kaiser Family Foundation, June 9)
House ACA Repeal Bill Puts Children with Disabilities and Special Health Care Needs at Severe Risk (Center on Budget and Policy Priorities, 6/14/17)
Impact of per capita caps on home and community-based services (Center on Budget and Policy Priorities, 5/18/17) (includes state-specific information on the number of people receiving Medicaid home and community-based care)