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US Senate unveils ACA repeal bill
World Report
US Senate unveils ACA repeal bill June 22, the Better Care Reconciliation Act, a bill designed to replace the Affordable Care Act, was revealed, among bipartisan concern and criticism. Aaron van Dorn and Rebecca Cooney report.
Consequences of the BCRA
The present Senate bill draft hews closely to the House’s AHCA: repealing the ACA’s taxes on high-income earners and insurance companies, as well as allowing states to waive the ACA’s essential health benefits—categories of coverage that insurers must include in their policies, including mental health and addiction services, maternal and pregnancy care, and drug coverage. These changes have the potential to go beyond the policies offered through the federal health insurance market to reach out to private insurance offered by employers. Although insurers would
be required to cover people with preexisting conditions, they would be able to charge them a premium, and could decline coverage for expensive treatments. Similarly, the bill also ends bans on annual and lifetime coverage caps.
“‘The BCRA...[is] an attempt to cut health care for low-income people, sick people, and older people in order to cut taxes for the wealthy’...” Importantly, the bill would make major changes to Medicaid, the pro gramme for Americans with a low income that provides funding for nearly two thirds of nursing homes and 76% of children from poor families. The BCRA would repeal Medicaid expansion and fundamentally change the way that the government funds the programme by introducing a per-beneficiary cap and by linking federal funding adjustments to a more conservative consumer price index. As a result, funding would be reduced by about US$800 billion over a decade. Shifting costs to the states, especially those that were part of the expansion, will produce budget shortfalls and ultimately require either programme cuts or reduce the number of Americans covered. “The BCRA is not an attempt to reform health care—rather, it’s an attempt to cut health care for lowincome people, sick people, and older people in order to cut taxes for the wealthy”, Thomas Huelskoetter, policy analyst for health at the Center for American Progress, a public policy research and advocacy organisation told The Lancet. “The BCRA would not only reverse the historic coverage gains that America has made under the Affordable
www.thelancet.com Published Online June 29, 2017 http://dx.doi.org/10.1016/S0140-6736(17)31760-9
Care Act, but would gut the Medicaid programme which has anchored our health-care safety net for more than 50 years. There’s no substitute for health coverage; on urgent health-care issues ranging from the opioid crisis to rural health access, the BCRA would set back our efforts to make progress for years to come.” The economics of the BCRA are a key determinant in its viability. The Congressional Budget Office (CBO) score released its report assessing the financial implications of the Senate bill on June 26. It estimates that by next year, 15 million more Americans would be uninsured, a number that would grow to about 22 million by 2026. Because of funding cuts and federal spending caps the BCRA places on Medicaid, the CBO estimates that enrolment would continue to decline beyond what their estimates show. Further, the report forecasts that by removing the individual mandate (requiring all Americans to maintain insurance coverage or face a tax penalty), premiums would jump by about 20% in 2018 compared with prices under the current law, but then drop by about 30% as benchmark
Published Online June 29, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31760-9
Aaron Bernstein/Reuters
The long and winding road toward health-care reform in the USA took yet another turn on June 22, 2017. Senate Majority Leader Mitch McConnell, on behalf of a group of 13 Republican Senators—all of whom are men— released a draft version of their Patient Protection and Affordable Care Act (ACA) replacement bill called the Better Care Reconciliation Act (BCRA). The reveal comes after weeks of clandestine meetings and drafting in secrecy, during which time Democratic Senators were excluded as well as many Republican Senators. The negotiations have been roundly criticised not only for being unusual, but also for what many historians and pundits suggest is a deliberately opaque and partisan decision process. The current level of animosity between the two parties in Congress and the overwhelmingly negative reception of the BCRA by Democrats is not surprising. The continued friction is largely a carry-over from the previous ACA repeal offering in the House of Representatives, the American Health Care Act (AHCA) which, because of the Republican majority in the House, was able to pass by a narrow 217-213 vote.
Senate Majority Leader Mitch McConnell speaks to the media about plans to repeal and replace ACA on Capitol Hill, June 27, 2017
1
World Report
plans would cover a smaller share of benefits and out-of-pocket costs would rise substantially. By contrast to the CBO estimate for the AHCA, the BCRA would reduce the federal deficit by another $202 billion, bringing the total net savings to $321 billion over the 2017–26 period.
A bill that faces strong opposition
Whether Republicans are actually able to pass the bill, however, is not certain. With 52 senators, a simple majority, Republicans can only afford to lose two votes (with a 50-50 tie broken by Vice President Mike Pence). Since the release of the CBO score, Senate Republicans’ reactions to the bill have been varied. Senator John Cornyn (Republican (R)-TX) called for a vote on the bill this week, while conservative senators like Paul Ryan (R-KY) and Ron Johnson (R-WI) have attacked the bill for not going far enough. Johnson criticised the bill in The New York Times, writing that the bill “also boosts spending on subsidies, and it leaves in place the pre-existing-condition rules that drive up the cost of insurance for everyone”. More moderate Republican senators have the opposite concerns, with Susan Collins (R-ME) announcing that she would be voting no on a motion to proceed on the bill, because of the level of cuts to Medicaid, a programme that rural, older Maine depends on. Senator Dean Heller (R-NV), who is up for reelection in 2018 for a hotly contested seat, also expressed skepticism about the bill, saying that he cannot support “a piece of legislation that takes away insurance from tens of millions of Americans”. Senators Rob Portman (R-OH) and Shelley Moore Capito (R-WV) have also expressed concerns over the continuing opioid epidemic, which the bill does not address substantially. Critics of the covert drafting process suggest that the bill purposefully did not address some of the concerns 2
so that they could be negotiated in amendments and allow senators in politically tricky situations to obtain concessions and get approval. Governors from across the political spectrum have also found the politics of the BCRA tricky to navigate. Republican Governors John Kasich (R-OH) and Brian Sandoval (R-NV) spoke out against the law, which would cause a substantial increase in the number of uninsured people in their states because of the repeal of the federal Medicaid expansion. Democratic Governor Andrew Cuomo (Democrat-NY) also called on his state’s congressional delegation—nearly a
“‘US Democrats and Republicans have fundamentally disagreed on the extent to which society should care for those who are vulnerable...The BCRA is a reflection of those different views.’” third of whom are Republican—to not support the passage of BCRA. “This heartless Republican Senate bill cannot and should not pass”, said Cuomo in a statement. “Every member of the New York delegation should be held accountable for doing everything within their means to stop this reprehensible bill from threatening our ability to combat the opioid crisis and stop the ever-rising death toll.” Opposition to the Senate bill by the medical community has been nearly universal, from the American Academy of Pediatrics, the American College of Physicians, to the American Heart Association, which have all stated strong opposition to the plan. The American Medical Association (AMA), which supported the ACA, said in a statement: “Medicine has long operated under the precept of Primum non nocere, or ‘first, do no harm.’ The draft legislation violates that standard on many levels.” The AMA statement pointed to the BCRA’s changes to
Medicaid and efforts to defund Planned Parenthood and restrict the types of plans federal funds can be spent on.
A reflection of fundamentally diverging perceptions of care
According to Anupam Jena, physician and professor of health-care policy at Harvard Medical School, the changes BCRA would make to the ACA represent a substantial difference in how the parties view health care at a fundamental level. “For decades, US Democrats and Republicans have fundamentally disagreed on the extent to which society should care for those who are vulnerable both economically and in health”, Jena told The Lancet. “The BCRA is a reflection of those different views. As it stands, compared to the Affordable Care Act, it trades off approximately $300 billion in reduced federal spending on Medicaid against 22 million fewer insured individuals over the next 10 years, as estimated by the [CBO].” “There are features of the bill that economists could rightly debate as to whether it’s the most ‘sound economic policy’”, said Jena, “but the underlying basis for the bill really reflects vast differences in the degree of altruism across party lines. Policy wonks who advocate for the bill are hard pressed, in my opinion, to offer any reasonable economic justification for the bill’s policies besides a desire to reduce federal spending at the cost of reduced health-care access for the poor, disabled, and elderly.” Despite previous assurances that a vote on the motion to proceed was imminent, McConnell announced on Tuesday that a vote would be delayed until after the July 4 recess. With only 3 weeks left in the Congressional calendar until September, and a deadline of September 30 to use reconciliation and its simple majority to pass a repeal of the ACA, any further delays could pose new obstacles for the bill.
Aaron van Dorn, Rebecca Cooney
www.thelancet.com Published Online June 29, 2017 http://dx.doi.org/10.1016/S0140-6736(17)31760-9
US Senate unveils ACA repeal bill June 22, the Better Care Reconciliation Act, a bill designed to replace the Affordable Care Act, was revealed, among bipartisan concern and criticism. Aaron van Dorn and Rebecca Cooney report.
Consequences of the BCRA
The present Senate bill draft hews closely to the House’s AHCA: repealing the ACA’s taxes on high-income earners and insurance companies, as well as allowing states to waive the ACA’s essential health benefits—categories of coverage that insurers must include in their policies, including mental health and addiction services, maternal and pregnancy care, and drug coverage. These changes have the potential to go beyond the policies offered through the federal health insurance market to reach out to private insurance offered by employers. Although insurers would
be required to cover people with preexisting conditions, they would be able to charge them a premium, and could decline coverage for expensive treatments. Similarly, the bill also ends bans on annual and lifetime coverage caps.
“‘The BCRA...[is] an attempt to cut health care for low-income people, sick people, and older people in order to cut taxes for the wealthy’...” Importantly, the bill would make major changes to Medicaid, the pro gramme for Americans with a low income that provides funding for nearly two thirds of nursing homes and 76% of children from poor families. The BCRA would repeal Medicaid expansion and fundamentally change the way that the government funds the programme by introducing a per-beneficiary cap and by linking federal funding adjustments to a more conservative consumer price index. As a result, funding would be reduced by about US$800 billion over a decade. Shifting costs to the states, especially those that were part of the expansion, will produce budget shortfalls and ultimately require either programme cuts or reduce the number of Americans covered. “The BCRA is not an attempt to reform health care—rather, it’s an attempt to cut health care for lowincome people, sick people, and older people in order to cut taxes for the wealthy”, Thomas Huelskoetter, policy analyst for health at the Center for American Progress, a public policy research and advocacy organisation told The Lancet. “The BCRA would not only reverse the historic coverage gains that America has made under the Affordable
www.thelancet.com Published Online June 29, 2017 http://dx.doi.org/10.1016/S0140-6736(17)31760-9
Care Act, but would gut the Medicaid programme which has anchored our health-care safety net for more than 50 years. There’s no substitute for health coverage; on urgent health-care issues ranging from the opioid crisis to rural health access, the BCRA would set back our efforts to make progress for years to come.” The economics of the BCRA are a key determinant in its viability. The Congressional Budget Office (CBO) score released its report assessing the financial implications of the Senate bill on June 26. It estimates that by next year, 15 million more Americans would be uninsured, a number that would grow to about 22 million by 2026. Because of funding cuts and federal spending caps the BCRA places on Medicaid, the CBO estimates that enrolment would continue to decline beyond what their estimates show. Further, the report forecasts that by removing the individual mandate (requiring all Americans to maintain insurance coverage or face a tax penalty), premiums would jump by about 20% in 2018 compared with prices under the current law, but then drop by about 30% as benchmark
Published Online June 29, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31760-9
Aaron Bernstein/Reuters
The long and winding road toward health-care reform in the USA took yet another turn on June 22, 2017. Senate Majority Leader Mitch McConnell, on behalf of a group of 13 Republican Senators—all of whom are men— released a draft version of their Patient Protection and Affordable Care Act (ACA) replacement bill called the Better Care Reconciliation Act (BCRA). The reveal comes after weeks of clandestine meetings and drafting in secrecy, during which time Democratic Senators were excluded as well as many Republican Senators. The negotiations have been roundly criticised not only for being unusual, but also for what many historians and pundits suggest is a deliberately opaque and partisan decision process. The current level of animosity between the two parties in Congress and the overwhelmingly negative reception of the BCRA by Democrats is not surprising. The continued friction is largely a carry-over from the previous ACA repeal offering in the House of Representatives, the American Health Care Act (AHCA) which, because of the Republican majority in the House, was able to pass by a narrow 217-213 vote.
Senate Majority Leader Mitch McConnell speaks to the media about plans to repeal and replace ACA on Capitol Hill, June 27, 2017
1
World Report
plans would cover a smaller share of benefits and out-of-pocket costs would rise substantially. By contrast to the CBO estimate for the AHCA, the BCRA would reduce the federal deficit by another $202 billion, bringing the total net savings to $321 billion over the 2017–26 period.
A bill that faces strong opposition
Whether Republicans are actually able to pass the bill, however, is not certain. With 52 senators, a simple majority, Republicans can only afford to lose two votes (with a 50-50 tie broken by Vice President Mike Pence). Since the release of the CBO score, Senate Republicans’ reactions to the bill have been varied. Senator John Cornyn (Republican (R)-TX) called for a vote on the bill this week, while conservative senators like Paul Ryan (R-KY) and Ron Johnson (R-WI) have attacked the bill for not going far enough. Johnson criticised the bill in The New York Times, writing that the bill “also boosts spending on subsidies, and it leaves in place the pre-existing-condition rules that drive up the cost of insurance for everyone”. More moderate Republican senators have the opposite concerns, with Susan Collins (R-ME) announcing that she would be voting no on a motion to proceed on the bill, because of the level of cuts to Medicaid, a programme that rural, older Maine depends on. Senator Dean Heller (R-NV), who is up for reelection in 2018 for a hotly contested seat, also expressed skepticism about the bill, saying that he cannot support “a piece of legislation that takes away insurance from tens of millions of Americans”. Senators Rob Portman (R-OH) and Shelley Moore Capito (R-WV) have also expressed concerns over the continuing opioid epidemic, which the bill does not address substantially. Critics of the covert drafting process suggest that the bill purposefully did not address some of the concerns 2
so that they could be negotiated in amendments and allow senators in politically tricky situations to obtain concessions and get approval. Governors from across the political spectrum have also found the politics of the BCRA tricky to navigate. Republican Governors John Kasich (R-OH) and Brian Sandoval (R-NV) spoke out against the law, which would cause a substantial increase in the number of uninsured people in their states because of the repeal of the federal Medicaid expansion. Democratic Governor Andrew Cuomo (Democrat-NY) also called on his state’s congressional delegation—nearly a
“‘US Democrats and Republicans have fundamentally disagreed on the extent to which society should care for those who are vulnerable...The BCRA is a reflection of those different views.’” third of whom are Republican—to not support the passage of BCRA. “This heartless Republican Senate bill cannot and should not pass”, said Cuomo in a statement. “Every member of the New York delegation should be held accountable for doing everything within their means to stop this reprehensible bill from threatening our ability to combat the opioid crisis and stop the ever-rising death toll.” Opposition to the Senate bill by the medical community has been nearly universal, from the American Academy of Pediatrics, the American College of Physicians, to the American Heart Association, which have all stated strong opposition to the plan. The American Medical Association (AMA), which supported the ACA, said in a statement: “Medicine has long operated under the precept of Primum non nocere, or ‘first, do no harm.’ The draft legislation violates that standard on many levels.” The AMA statement pointed to the BCRA’s changes to
Medicaid and efforts to defund Planned Parenthood and restrict the types of plans federal funds can be spent on.
A reflection of fundamentally diverging perceptions of care
According to Anupam Jena, physician and professor of health-care policy at Harvard Medical School, the changes BCRA would make to the ACA represent a substantial difference in how the parties view health care at a fundamental level. “For decades, US Democrats and Republicans have fundamentally disagreed on the extent to which society should care for those who are vulnerable both economically and in health”, Jena told The Lancet. “The BCRA is a reflection of those different views. As it stands, compared to the Affordable Care Act, it trades off approximately $300 billion in reduced federal spending on Medicaid against 22 million fewer insured individuals over the next 10 years, as estimated by the [CBO].” “There are features of the bill that economists could rightly debate as to whether it’s the most ‘sound economic policy’”, said Jena, “but the underlying basis for the bill really reflects vast differences in the degree of altruism across party lines. Policy wonks who advocate for the bill are hard pressed, in my opinion, to offer any reasonable economic justification for the bill’s policies besides a desire to reduce federal spending at the cost of reduced health-care access for the poor, disabled, and elderly.” Despite previous assurances that a vote on the motion to proceed was imminent, McConnell announced on Tuesday that a vote would be delayed until after the July 4 recess. With only 3 weeks left in the Congressional calendar until September, and a deadline of September 30 to use reconciliation and its simple majority to pass a repeal of the ACA, any further delays could pose new obstacles for the bill.
Aaron van Dorn, Rebecca Cooney
www.thelancet.com Published Online June 29, 2017 http://dx.doi.org/10.1016/S0140-6736(17)31760-9