After their initial attempt at passing a bill to repeal or replace Obamacare, on Thursday Republicans unveiled a new Senate health care bill. Like the previous Senate bill, the new version of the Better Care Reconciliation Act starts from a similar framework as the Affordable Care Act in 2010, giving subsidies to lower income people to help pay for health insurance on the individual market, and preventing insurers from banning people based on having pre-existing conditions. And like the previous version of the bill, the second iteration of the BCRA lowers the amount paid in those subsidies compared to Obamacare, lowers the minimum value of insurance that can be bought with subsidies, cuts Medicaid funding (which had been expanded by Obamacare) and cuts many of the taxes that paid for Obamacare.
But in this version of the bill, some of the biggest shifts in spending from the first iteration of the BCRA have been lessened. The new draft keeps some of Obamacare's taxes on high earners—$231 billion of them—that had been cut from the initial bill. This seems like a response to the attack from Democrats—and even some Republicans—that the Republican health plan pays for tax cuts for the rich by slashing medical care for the poor. And it uses some of that money to pay for an additional $70 billion to share costs for insurers of covering high-cost patients, hopefully allowing premiums to go down. And there's an additional $45 billion allocated specifically to fight the opioid epidemic.
But that money to fight the opioid epidemic clashes with one of the biggest effects of BCRA that wasn't changed in this new version of the bill—it still cuts $772 billion from Medicaid, which, in addition to providing health coverage to millions, is a primary source of aid to those battling opioid addiction. Governor John Kasich of Ohio, a Republican who had come out strongly against the previous iteration of the bill, said that spending "a few billion dollars on opioids" while cutting far more from Medicaid would be "like spitting in the ocean." For some of the moderate Republican senators hailing from states that had expanded Medicaid—such as Susan Collins (R-MN), Lisa Murkowski (R-AK), Shelly Moore Capito, (R-WV), and Dean Heller (R-NV), these cuts to the program had been the biggest sticking point in the legislation. But despite their complaints, massive cuts to Medicaid spending haven't changed in the new bill.
McConnell’s Medicaid offer is this: Nothing. https://t.co/K76n432anI— Dylan Scott (@dylanlscott) July 13, 2017
But while moderates weren't given the big ask they were looking for to change their votes from "no" or "uhhh..." to "yes," some of the hard-line conservatives who had opposed the Senate bill for not going far enough did get a version of what they wanted. Senator Ted Cruz had proposed an amendment that would allow health insurers to provide plans that didn't cover all of the Essential Health Benefits (stuff like maternity care, prescription drugs, emergency room trips) that had been mandated in Obamacare as long as there was one plan offered that included them all.
The amendment was opposed by nearly the entire health care industry and many health policy experts, pointing to how it could potentially lead to healthy people buying the skimpy insurance for cheap, and only sick people who would cost a ton for insurers shelling out for the full insurance. In other words, while coverage for pre-existing conditions would be technically guaranteed under the law's regulations, the insurance someone with a pre-existing condition could buy might be prohibitively expensive.
To deal with this problem, while a version of Cruz's Amendment is included in the bill, the bill uses $70 billion in additional funding in cost-sharing payments to the insurance industry to lower the costs of expensive insurance. But that funding would sunset in 2026, suggesting that new money would need to be allocated to stop increases in costs for sick people.
The effects of BCRA 2.0 in 2026 vs. 2027 would differ dramatically. Premiums for compliant plans will skyrocket in 2027. https://t.co/H8H0Te3K2Q— Loren Adler (@LorenAdler) July 13, 2017
The bill also expands the use of Health Savings Accounts, tax-free allocations of people's income that they can use to pay for medical expenses. The bill allows individuals to use HSAs to pay for premiums on insurance plans, which would in-effect lower the out-of-pocket costs for many. However, some on the left have taken issue with the focus on HSAs, since they are more usable to people who already have money and have less trouble paying premiums.
One sizable change that the BCRA makes from current law that hasn't been touched in the new version is denial of Medicaid or Medicare funds for non-abortion medical treatment (including maternity care, STI treatment, and pre-natal care) paid towards certain health centers that perform abortion, most notably Planned Parenthood. Cecile Richards, President of Planned Parenthood Federation of America said in a statement:
We don't know exactly how many people might lose health coverage from this bill, or whether it would be less than the 22 million projected under the previous version. Just hours after the bills unveiling, it already hit trouble. Senators Susan Collins (R-MN), Rob Portman (R-OH), and Rand Paul (R-KY) all announced that they would not support a Motion To Proceed, meaning that the bill lacks the 50 necessary votes to even come to the Senate floor for a vote. Collins and Portman expressed opposition to a bill that still cuts health care from their residents more than they can stomach, and Paul has staked out a position in opposition to this whole bill for preserving Obamacare's framework of subsidizing private health insurance at all. It seems that after six months, two versions of the House bill, two versions of the Senate bill, and numerous back-room negotiations and arm-twisting sessions, the Republicans still can't agree on what they want to replace Obamacare with.