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July 20, 2017

Senate will vote on health reform next week, leaders pledge—but on what bill?

Daily Briefing

    Senate GOP leaders on Wednesday reaffirmed their plans to vote next week on motion to proceed with a health reform bill, but had yet to decide which bill they would seek to advance. 

    Learn the 3 steps to establishing an intentional Medicare risk strategy

    Senate Majority Leader Mitch McConnell (R-Ky.) on Monday announced that the Senate would no longer move forward with the Better Care Reconciliation Act (BCRA). Instead, he said, the Senate would consider a "repeal-and-delay" measure that would immediately repeal parts of the ACA while giving GOP lawmakers more time to come up with a plan to replace the law's coverage expansions. The Congressional Budget Office (CBO) scored that approach on Wednesday, finding that it would reduce deficits by $473 billion but increase the uninsured population by 32 million by 2026.

    But by mid-week, McConnell was suggesting the BCRA was back on the negotiating table. CBO released its score of the latest version of that bill on Thursday, estimating that it would reduce deficits by $420 billion but increase the uninsured population by 22 million people by 2026. 

    Speaking at the White House after a lunch with Trump Wednesday, McConnell said, "I think we all agree it's better to both repeal and replace, but we could have a vote on either." 

    It is not clear that either proposal has the support needed to advance to the Senate floor. At least 50 Senate Republicans, plus the vice president, need to support the motion to proceed to start debate on legislation. With Sen. John McCain (R-Ariz.), who on Wednesday announced he had been diagnosed with brain cancer, at home considering treatment options, senators can afford to lose only one GOP senator's vote.

    As of Wednesday, at least three GOP senators continued to oppose the repeal-and-delay plan and, according to Politico, Sens. Rand Paul (R-Ky.) and Susan Collins (R-Maine) were still opposed to the revised BCRA.

    The first option: Revived 'repeal-and-delay' would leave 32M uninsured by 2026 

    The revived repeal-and-delay bill would increase the United States' uninsured population by 32 million people and roughly double health plan premiums by 2026, according to a report released Wednesday by the CBO and the Joint Committee on Taxation.

    The latest bill, called the Obamacare Repeal Reconciliation Act of 2017, is an updated version of a 2015 bill that congressional Republicans passed and former President Barack Obama vetoed. Similar to the 2015 version, the updated bill would immediately repeal major ACA provisions, including the law's individual and employer mandates and some of the law's tax increases, and in 2020 it also would eliminate funding for the law's Medicaid expansion and insurance premium subsidies. The idea would be that Congress would pass an ACA replacement plan in the interim. 

    CBO projected that the revived repeal-and-delay measure would increase the number of uninsured by 17 million people in 2018, compared with current law. Those numbers would grow to 20 million by 2020 and 32 million by 2026.

    CBO said the repeal of the individual mandate would account for the majority of coverage losses in 2018, and without congressional action those losses would continue to grow after the enhanced Medicaid funding and insurance subsidies are eliminated in 2020. CBO estimated that, by 2026, federal funding for Medicaid would fall by $842 billion and 19 million fewer people would be enrolled in the program.

    The report said by 2026 about 11 million more people would receive insurance through their employer.

    Premiums in the non-group market would increase by about 25 percent in 2018, compared with current law. That increase "would reach about 50 percent in 2020, and premiums would about double by 2026," the CBO report stated.

    CBO also projected that changes under the bill would cause some insurers to leave the individual market in 2018, and by 2026, 75 percent of the nation's population could be living in areas without any individual coverage options.

    Overall, CBO estimated the bill would reduce the federal deficit by $473 billion from 2017 to 2026.

    The second option: Updated Better Care Reconciliation Act would leave 22M uninsured by 2026

    Meanwhile, the updated BCRA would increase the United States' uninsured population by 22 million people by 2026 and reduce federal deficits by $420 billion over the next decade, according to a report released Thursday by CBO and the Joint Committee on Taxation.

    The score largely tracked that of a previous version of the bill scored on June 26. CBO found the updated BCRA "would have similar effects on the number of uninsured people," with estimates differing by no more than 500,000 people in any year over the next decade.

    Further, CBO found the updated BCRA would lower average premiums for a benchmark plan in the nongroup market by about 25 percent in 2026, relative to current law—compared with 20 percent under the previous version of the bill. CBO attributed the decline to an additional $51 billion in funding for the State Stability and Innovation Program to lower the cost of coverage for low-income people.

    The benchmark plans would likely carry high deductibles, CBO found. In 2026 an illustrative benchmark plan would have a deductible for medical and drug expenses combined of about $13,000, CBO estimated—compared with roughly $5,000 for the more generous illustrative benchmark plan outlined under current law.

    In addition, CBO estimated that federal spending on Medicaid would fall by 26 percent over the next decade. CBO said about 75 percent of the reduction would come from provisions that scale back the ACA's Medicaid expansion.

    CBO further estimated that relative to current law, the updated BCRA would reduce federal deficits by $420 billion over the next decade, compared with $321 billion under the previous bill. CBO said those additional savings would be achieved by "reducing spending for Medicaid and subsidies for nongroup health insurance"

     (Small, FierceHealthcare, 7/19; Cancryn, Politico, 7/19; CNBC, 7/19; Groppe, USA Today, 7/19; CBS News, 7/19; Everett et al., Politico, 7/19; Litvan et al., Bloomberg, 7/19; CBO report, 7/19; CBO report, 7/20).

    Is your Medicare risk strategy MACRA-ready?

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