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Update on Health System Reform in the Senate
While there was considerable activity in the Senate this week, plans for bringing a health system reform bill to the floor for a vote remain very fluid. Up until this week, Majority Leader McConnell could only afford to lose two Republican votes to pass an Affordable Care Act (ACA) “repeal and replace” bill, and with the sad news that Senator John McCain’s illness may keep him away from Washington next week that number could be reduced to one. Nevertheless, under pressure from both from President Trump and a long legislative to-do list, Senator McConnell said he will attempt to bring repeal legislation to the floor next Tuesday.
Senators will be asked on Tuesday to approve a motion to open debate on the House-passed American Health Care Act, H.R. 1628. At this point, it appears that two substitute amendments for the House-passed text are likely candidates to serve as the basis for Senate debate and amendment:
- A revised version of the Obamacare Repeal and Reconciliation Act (ORRA), vetoed by President Obama in 2015, that eliminates mandate penalties as well as all premium subsidies and Medicaid expansion funds; or
- The Better Care Reconciliation Act (BCRA), with modification that include additional funding for opioid addiction treatment and for market stabilization, among other changes.
It is unclear whether there are 50 votes to approve the motion to proceed, let alone for passage of either of these substitute amendments (which could be revised further before Tuesday). To date, enough Senators have expressed opposition to proceeding to either substitute to block its consideration, though negotiations are ongoing.
The Congressional Budget Office (CBO) issued the following estimates of the impact on spending and insurance coverage for various ACA repeal and replace bills.
|AHCA (5/24)||BCRA (6/26)||ORRA (7/19)||BCRA rev. (7/20)|
|Deficit reduction||-$119 billion||-$321 billion||-$473 billion||-$420 billion|
|Medicaid cut||-$834 billion||-$772 billion||-$842 billion||-$756 billion|
|Tax credits/ premium subsidies||-$276 billion||-$408 billion||-$454 billion||-$396 billion|
|2018 uninsured||+ 14 million||+ 15 million||+ 17 million||+ 15 million|
|2026 uninsured||+ 23 million||+ 22 million||+ 32 million||+ 22 million|
|2018 premiums||+ 20%||+ 20%||+ 25%||+ 20%|
|2026 premiums||– 20%||– 20%||+100%||– 25%|
Given the AMA’s objectives for health system reform, first shared with the new Congress on January 3, the AMA cannot support either Senate proposal due to the negative impact on coverage, affordability, and Medicaid.
The AMA’s position remains rooted in its policy, which supports expanding access to affordable and meaningful health insurance coverage and preserving the safety net provided by Medicaid. We acknowledge the flaws of the ACA, and renew our call for Congress to engage with stakeholders in a thoughtful, bipartisan process to improve coverage and access to care for all Americans.