Senate Majority Leader Mitch McConnell released on Thursday a revision of the Better Care Reconciliation Act, the Senate's Affordable Care Act repeal-and-replace bill. A vote on a previous version of the bill was canceled after it failed to attract sufficient support among Republicans, in no small part because the Congressional Budget Office concluded it would result in 22 million fewer Americans having health insurance in 2026.
The revised draft of the BCRA makes a few changes to the previous draft. As expected, the bill includes a modified version of the Cruz-Lee amendment—in order to access certain federal stabilization funds associated with high-cost patients, insurers would have to offer on-exchange ACA-compliant plans (but could also offer non-compliant plans). The bill also sets aside an additional $70 billion in state stabilization grants (bringing the total to $132 billion), which states could use to stabilize the ACA-compliant risk pools (those risk pools would presumably be in a fragile state due to risk segmentation). One percent of reinsurance funds in the bill would be set aside for states with particularly high premiums, a provision that analysts have suggested may be targeted at winning the support of Senator Lisa Murkowski (R-Alaska), who has been a vocal skeptic of the bill and lives in a state with very high health insurance costs.
On top of the $50 billion worth of short-term federal stabilization funds in the bill, this means that the revised version of the BCRA now includes lots of money for insurers, as Larry Levitt of the Kaiser Family Foundation points out:
There are a few additional concessions to conservatives in this draft: People would be able to use HSA, or health savings account, funds to pay their health insurance premiums and government tax credits to buy much skimpier health insurance plans than is currently permitted.
Surprisingly, there's not really much in here for moderates, aside from the additional state stabilization funds. The new version of the BCRA does keep some of the ACA's taxes in place (a change from the previous version). But it doesn't make any changes to the structure of the premium tax credits in the previous draft, which (in comparison to the ACA) are pegged to skimpier, higher-deductible plans and are skewed more toward younger people. An analysis by the Kaiser Family Foundation concluded that, under the BCRA, individuals would pay about 74 percent more (after premium tax credits) for comparable, silver-level coverage than under current law.
This draft also maintains the deep cuts to Medicaid that were in the previous version and that so distressed moderate Republicans, although there are a few tweaks that may win some support. States would be able to apply for waivers from Medicaid spending caps to provide home and community-based services to certain populations or in the event of a declared public-health emergency (Vox has more detail on this). The bill also includes an additional $45 billion worth of funding for substance abuse treatment, a concession to moderates in states that have been hard-hit by the opioid epidemic, such as Senators Shelley Moore Capito (R-West Virginia) and Rob Portman (R-Ohio).
A CBO score of the updated legislation is expected on Monday, although health-care experts—and, reportedly, Senator Susan Collins (R-Maine)—don't expect that this revised version will dramatically improve coverage numbers. Both Collins and Senator Rand Paul (R-Kentucky), meanwhile, have already said they'll vote against a motion to begin debate on the bill. And, in other news, Senators Lindsey Graham (R-South Carolina) and Bill Cassidy (R-Louisiana) unveiled their "alternate" health-care plan on CNN shortly before Senate leadership briefed members on the updated BCRA, a move that reportedly further complicates leadership's efforts to get to 50 votes on the BCRA.