Defeating The Better Care Reconciliation Act

The bill unveiled Thursday by Senate Republicans has been out in the open for less than a week, and it is drawing nearly universal criticism from members of Congress, policy leaders, and all of the major health care players: hospitals, providers, patient and consumer groups, and advocacy organizations. Here's a rundown of what's in the bill and how you can help protect the health care of millions by ensuring its defeat.

The Senate bill mirrors the worst of the House bill, known as the American Health Care Act, with some stunning additions. For a detailed unpacking of the bill, read this Health Affairs Blog article by Timothy Jost and Sara Rosenbaum, or scroll down, to read a summary.

To get an idea of how this week may play out, click here. There will likely be changes made to the bill this week to overcome concerns of individual Republicans, in order to get to the 50 votes needed. They may delay harmful provisions, undo some of the cuts, or add small amounts of money to address big problems. None of these will fix the structural problems with the bill.

Medicaid   

  • Retains nearly all damaging provisions in House AHCA, including the draconian per capita caps;
  • Regarding the Medicaid Expansion: 
    • Phases out the enhanced federal match over 3 years, beginning in 2020;
    • Repeals Essential Health Benefits for the expansion population;
  • Reduces rate of increase in state per capita caps beginning in 2025;
  • Allows states to impose work requirements; 
  • Blocks Medicaid funding to Planned Parenthood for one year; 

Private Market 

  • Includes subsidies that are more similar to ACA than to AHCA, but less generous. 
  • Phases out subsidies at 350% FPL, rather than ACA's 400% FPL, stripping affordable insurance from moderate-income families.
  • Adds age component to subsidies and makes them more generous for younger individuals, less generous for older. For example, a 60-year-old with income between 300 and 350 percent of the FPL would have to spend 16.2 percent of household income on premiums before becoming eligible for APTC, while a 28-year-old would only have to pay 4.3 percent. Under the ACA, both would have had to pay 9.5 percent. 
  • Makes individuals eligible for employer coverage ineligible for premium tax credits regardless of the affordability of the employer coverage. For details on premiums and tax credits by county, see the Kaiser Family Foundation interactive map.
  • Changes the benchmark plan to be roughly equivalent to the lowest-cost bronze plan under ACA, leaving people with much higher out of pocket costs.
  • Funds the Cost-Sharing Reductions through 2019, then repeals them, greatly increasing out of pocket costs for the lowest-income families.
  • Maintains AHCA's 5:1 age bands, meaning premiums can cost up to 5 times more for an older person than a younger one. ACA is 3:1.
  • Repeals the individual mandate, but does not provide any mechanism to incentivize continuous coverage to prevent adverse selection and maintain market stability. 
  • Does not permit waivers of community rating, but does allow states to see waivers of essential health benefits, out of pocket limits, and actuarial value requirements, so those with pre-existing conditions would still be at risk. 
  • Eliminates the "Section 1332" waiver guardrails that require waivers to be budget neutral, cover as many people, and maintain the same affordability.

There will likely be changes made to the bill this week to overcome concerns of individual Republicans, in order to get the 50 votes needed. They may delay harmful provisions, undo some of the cuts, or add small amounts of money to address big problems. None of these will fix the structural problems with the bill

We expect the process to move very quickly, with a vote by Thursday or Friday (see post directly below), so it is critical that we do all we can to make our voices heard. Make sure to read our latest Action Alert to see how you can help this week.