Mitch McConnell and the Senate Republicans introduced their revised Better Care Reconciliation Act (BCRA) yesterday. As of this morning, both Sen. Susan Collins and Rand Paul have opposed a motion to proceed on bringing the bill up for consideration to vote. This leaves the Affordable Care Act (ACA) repeal-and-replace in uncertainty, as 3 “No” votes would be enough to doom any chances of passing the Senate. Experts have said that they don’t expect the changes in this bill to alter the CBO’s previous estimate that 22 million could lose their health insurance coverage if passed. This may not matter, as Republicans have made it evident that they could try to push for a vote before the CBO concludes its analysis of the new bill.
Here are the main revisions from the previous bill, with some perspective from Vox:
Cuts to Medicaid remain unchanged, as does the shrinking of Medicaid expansion that more than 30 states have accepted and new patients have found satisfying. Both Republican opposition and citizen outcry thus far have been focused at these severe cuts to Medicaid, which covers half of the births in this country and 1 in 5 Americans, including 2 in 5 children and 2 in 3 nursing home residents. Shrinking the ACA’s program to expand Medicaid is also significant. The CBO has concluded in a separate analysis that these proposed cuts would shut off additional states from accepting Medicaid expansion, and would force some states that have accepted it to drop out, resulting in millions losing coverage.
Denying coverage based on pre-existing conditions has returned to Republican’s healthcare legislation. However, it has become more complicated (likely on purpose), so we’ll spend a little more time discussing it.
You may remember that the first rendition of BCRA left out what the House bill (AHCA) included concerning pre-existing conditions. But Sen. Ted Cruz has offered a new amendment included in the revised BCRA that returns a backdoor option for denying those with chronic health problems. As long as health insurers offer a comprehensive plan – that is, one with essential benefits that the ACA requires to be provided – they can also offer skimpier, deregulated plans. These deregulated plans give more control to insurers in raising costs so high that individuals with pre-existing conditions cannot afford to pay them. Thus, those with chronic health problems will be forced to buy the more expensive and comprehensive plans.
This has several avenues of predictable outcomes that all lead to an unstable marketplace. Ultimately two types of coverage will form: (1) cheap, barebones coverage for rich, healthy individuals, and (2) expensive (or unaffordable), comprehensive coverage for poor, sick individuals. This is explained by Vox author, Sarah Kliff:
Health policy experts know exactly how this would play out: Healthy people would pick the skimpier plan, while the comprehensive plan would essentially become a high-risk pool for sicker Americans.
Individual market enrollees would likely game the system too. A couple expecting a baby, for example, would be expected to upgrade to the [comprehensive] plan that covers maternity care for one year before returning to the cheaper plan they had before.
This tipping of the scales alone could be enough to make comprehensive plans too unaffordable for most individuals, forcing them out of coverage. Those looking to join a comprehensive plan will still be eligible to receive a tax credit in BCRA. However, out-of-pocket costs for deductibles and premiums would remain unbelievably unaffordable. For example, the CBO estimates that a 64-year old earning $11,500 would still need to pay $4,800 for a comprehensive health insurance plan.
Pre-tax money could be used to pay for premiums. Americans enrolled in health savings accounts (HSA), nearly 29% of workers, could now use this money to pay for premiums in addition to their co-pays and co-insurances. This is a great added benefit to those with HSAs, but falls short as a stand-alone option for those who struggle to afford health insurance premiums in the first place. And, as you may know if you have an HSA, this often doesn’t cover the entire cost of a premium.
Wealthy Americans would get less of a tax cut in the revised BCRA. The previous bill included more than $500 billion in tax cuts for high-income individuals and manufacturers. Republican writers decided to extend both a 0.9% investment tax and 3.8% Medicare payroll surtax from ACA that target wealthier individuals.
Keeping these two taxes in place would net the government an estimated $231 billion in revenue over the next decade, and eliminate some of the benefits high-income Americans would have received under the first draft.
Finally, the revised bill provides $45 billion to combat opioid abuse. But as Joshua Sharfstein, professor at the Johns Hopkins Bloomberg School of Public Health, says
The $45 billion they’ve added is a drop in the bucket compared to the amount of money that would be lost in the Medicaid cuts ($800 billion). It’s a tiny fraction of what Medicaid is already providing millions of people.
Think about it. Those addicted to and abusing pain-killing drugs need actual care through sustained coverage – which Medicaid provides – rather than an indiscriminate number of dollars. When you consider that funding for this opioid abuse program constitutes less than 6% of the total cuts imposed to Medicaid, it is sadly apparent that this is included mostly as political leverage. That is, ammunition for BCRA’s supporters to attack those who oppose the bill as a whole for any other legitimate reason.
Despite these poorly addressed flaws, a vote could happen this week. The voice of the people has made a difference at each step of the healthcare reform process. With just 12% approval and millions of lives at stake, BCRA will require sustained pressure on our elected officials. You can use the Trumpcare Toolkit to reach make your voice heard, and if you’re a member of the medical community searching for the right words, here is a great perspective to get you started.