Fresh off their July 4 recess, Senate leaders are trying to revive and pass their health overhaul bill over the next few weeks. They are expected to release an updated draft of their bill—the “Better Care Reconciliation Act (BCRA)”—this week, which would be followed by a score from the non-partisan Congressional Budget Office (CBO) early next week. On July 11, Senate leaders announced they would work through the first two weeks of the monthlong August recess to consolidate support and hold a floor vote on the legislation.
Additional changes to the Senate’s legislative proposal are necessary in order to gain the simple majority votes needed for passage under the fast-track budget reconciliation procedure. On June 27, 2017 Senate Majority Leader Mitch McConnell (R-Ky.) announced he was postponing the planned vote on the legislation, the “Better Care Reconciliation Act (BCRA) of 2017,” when it was clear he did not have the support from at least 50 Senators to proceed. Leader McConnell can only lose two Republican votes on both the procedural motion to proceed to a vote and on an actual up or down vote on the Senate floor.
CBO is reportedly reviewing various pieces of legislative language that would likely produce a different score than the one released on June 26, 2017. Nevertheless, the same June 26 CBO report that caused reservations amongst some Republicans also produced a figure that is aiding Leader McConnell in his negotiations. Specifically, an additional $188 billion can be spent in the Senate proposal without violating procedural rules. This is because CBO estimates that the BCRA, as currently written, reduces the federal deficit by $188 billion more than the House-passed “American Health Care Act (AHCA) of 2017.”
To reach consensus, Leader McConnell is trying to balance complex competing interests in his caucus. Some Republican Senators, including Rand Paul (R-Ky.), Mike Lee (R-Utah), Ron Johnson (R-Wis.) and Ted Cruz (R-Texas), do not support the BCRA as drafted because they believe it does not go far enough in repealing the Affordable Care Act. More moderate Republican Senators, including Dean Heller (R-Nev.), Rob Portman (R-Ohio) and Shelly Moore Capito (R-W.V.), have concerns with the severity of the cuts to Medicaid and how this would impact the response to the opioid epidemic in their states. To complicate matters, other moderate Republicans such as Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska) have additional concerns including the defunding of Planned Parenthood.
To attempt to solve what has been described as a “Rubik’s cube,” Leader McConnell is reportedly considering various ideas, such as maintaining the net investment income on high-income earners (repealed in the current version of BCRA), which would free up money to enhance subsidies for low-income individuals and older adults. It has also been reported that he is considering allowing pre-tax health savings accounts to be used to pay for insurance premiums. In a nod to Republican senators whose states have been particularly hard hit by the opioid epidemic, he is also considering increasing the current $2 billion dedicated to the opioid response to $45 billion.
As Leader McConnell weighs changes that would appease moderate Republican senators, he has faced resistance from more conservative Republican senators who want to see the elimination of more regulations. Senator Ted Cruz (R-Texas) is circulating a proposal that would do just this, effectively allowing companies to offer health insurance plans that adhere to all of the ACA’s regulations with some government subsidies while also allowing them to offer plans that do not comply. This proposal is reportedly also being scored by CBO, although no legislative text has been made public. While experts continue to debate the feasibility of such proposals, the Senate parliamentarian must also determine whether these ideas abide by the chamber’s strict procedural rules.
The original 142-page discussion draft that was first released on June 22, 2017 has already undergone changes. A new version was released on June 26, 2017 that included technical fixes and a continuous coverage provision which would make individuals wait six months before enrolling in health insurance if they had a break in coverage of more than 63 days in the previous 12 months. Without such a provision, which the CBO included in their analysis, experts predicted that the insurance markets would have collapsed. Both the House and Senate bills repeal the Affordable Care Act’s individual mandate, which requires individuals to have health insurance.
The U.S. House of Representatives passed their health overhaul bill, the “American Health Care Act (AHCA) (H.R. 1628),” on May 4 after multiple high-profile attempts. Senate leadership and the administration hope to avoid such public failures. Congress and the administration want to avoid extending the health overhaul bill beyond the August recess, especially since there are other legislative priorities that must be resolved before the end of this fiscal year.
NACo continues to urge you to contact your Senators to oppose the bill. To learn why NACo opposes the bill and view our up-to-date analysis, click here.