The United States Senate just voted against the Obamacare Repeal Reconciliation Act, which the GOP released last week and is modeled on the Affordable Care Act repeal legislation the Senate passed back in 2015. ORRA would have repealed, with a delay, much of the ACA, including the Medicaid expansions, the subsidies for low-income Americans, the individual and employer mandates, and many of the ACA's taxes, without putting an immediate replacement in place. Seven Republicans—Senators Lamar Alexander (R-Tennessee), Shelley Moore Capito (R-West Virginia), Susan Collins (R-Maine), Dean Heller (R-Nevada), John McCain (R-Arizona), Lisa Murkowski (R-Alaska), and Rob Portman (R-Ohio)—voted against the legislation.
Repeal-and-delay, the GOP's initial strategy for replacing the ACA, quickly fell apart back in January after President Donald Trump expressed his support for simultaneously repealing and replacing the ACA, and some Republicans subsequently expressed concerns about how disruptive such a strategy would be to the insurance markets. In a score published last week, the Congressional Budget Office predicted the ORRA would result in 17 million more Americans going uninsured in 2018 (as opposed to under the ACA), and 32 million by 2026. Those numbers are quite a bit higher than the coverage losses the CBO predicted under recent versions of the American Health Care Act (23 million by 2026) and the Better Care Reconciliation Act (22 million by 2026). The CBO also projected premiums skyrocketing by 25 percent in 2018 under the ORRA, 50 percent by 2020, and doubling by 2026. The ORRA would also wreak havoc on the non-group markets: According to the CBO's projections, under the ORRA, half of the nation's population would live in regions of the country with no insurers participating in the markets by 2020. That figure would jump to 75 percent by 2026.
The consequences of the ORRA would be particularly dire because of the constraints of the reconciliation process. Under reconciliation, Republicans are limited in how much of the ACA they can roll back; specifically, many of the law's regulations on health-insurance plans cannot be repealed without 60 votes (which Republicans don't have). Repealing the financial subsidies and mandates that encourage healthy people to buy insurance, while leaving in place the regulations that require insurers to offer comprehensive coverage to those with pre-existing conditions at the same rates as others in the community, is essentially a recipe for an insurance market death spiral.