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Why and How to Avoid High-Risk Pools for Americans with Preexisting Conditions

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http://www.commonwealthfund.org/publications/blog/2017/jun/how-and-why-to-avoid-high-risk-pools

Image result for pre existing conditions

The American Health Care Act (AHCA)—the U.S. House of Representatives’ bill to repeal and replace the Affordable Care Act (ACA)—would allow states to apply for waivers to reduce existing consumer protections and provide funding for states to set up high-risk pools or other mechanisms for people with preexisting conditions who have lapses in their coverage. In previous posts, I have talked about the high costs and meager coverage associated with high-risk pools that operated before the ACA and the fact that their use did not significantly reduce costs for other people who buy their own health plans in the individual market. Moreover, the Congressional Budget Office analysis of the AHCA finds that the funding it makes available to states for the high-risk pools is inadequate.

In a recent commentary for Annals of Internal Medicine on high-risk pools, I note that people with preexisting conditions constitute roughly 51 percent of Americans. Here, let’s explore who might end up in a high-risk pool, what their experiences might be, and policymakers’ alternative options for stabilizing the marketplaces.

The U.S. Department of Health and Human Services (HHS) estimated that 23 percent of Americans with preexisting conditions had a period of uninsurance in 2014, often because of job changes or periods of financial instability. Young people reaching age 26 who transition off their parents’ coverage also sometimes experienced gaps in coverage—and some of them have preexisting conditions. Should the AHCA become law, individuals with preexisting conditions and lapses in coverage who live in states that obtain waivers to allow insurers to charge people based on their health would likely end up in high-risk pools.

Research has shown that the greater out-of-pocket costs and limited coverage associated with high-risk pools led to enrollees forgoing needed care and experiencing worse outcomes. In fact, before the ACA, high-risk pool enrollees in Kansas were eight times more likely to transition to federal disability programs than members of the general population with these conditions.

Current Medicaid beneficiaries also would be affected. The Congressional Budget Office analysis of the AHCA estimated that 14 million fewer people would have Medicaid coverage as a result of the federal funding cuts. Many of them would be forced to look to the individual insurance market to gain coverage, yet half of these former Medicaid beneficiaries would have serious preexisting conditions. Given the historically very high costs for consumers associated with high-risk pools, the majority of these individuals would likely go uninsured instead. Many would end up using the emergency room to access care once their needs become urgent, and their uncompensated health care costs would be borne by others with insurance. Some would likely suffer serious health consequences, even preventable deaths.

Supporters of the AHCA suggest that the legislation gives states more options to design coverage for their citizens, thereby better meeting their needs. Section 1332 of the ACA, however, already gives states a great deal of flexibility in designing their marketplaces while still providing comprehensive and affordable coverage. Indeed, both Alaska and Minnesota are pursuing 1332 waiver programs to specifically address concerns about high-risk individuals by implementing reinsurance programs, rather than segregating people with preexisting conditions into high-risk pools. These programs would maintain the overall larger pool of insured people in the state while protecting insurers against catastrophic costs. Reinsurance programs, such as the one temporarily instituted under the ACA for its first three years, have historically been proven to bring down premium costs for everyone. Given that reinsurance programs are a more effective and evidence-based mechanism for stabilizing the individual insurance market, state policymakers should strongly consider pursuing these programs under the existing ACA rules instead of establishing high-risk pools. And, federal policymakers should acknowledge and support this mechanism to strengthen the marketplace, bring down costs, and encourage participation by insurers.

 

Senate’s Updated ACA Repeal-and-Replace Bill Will Still Leave Millions Uninsured

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http://www.commonwealthfund.org/publications/blog/2017/jul/senate-updated-aca-repeal-and-replace-bill?omnicid=EALERT1242189&mid=henrykotula@yahoo.com

Yesterday, Senate Republicans introduced an updated version of the Better Care Reconciliation Act (BCRA), their proposed repeal and replacement of the Affordable Care Act (ACA). The revised bill makes changes aimed at winning over Republicans who oppose the bill.

The Congressional Budget Office (CBO) projections of the updated bill’s effects on coverage and the federal budget are not available yet, but it is still likely to significantly increase the number of uninsured Americans — and raise health care spending for low- and moderate-income people. While the updated bill would leave the ACA’s taxes on higher-income people in place, providing an estimated $231 billion in additional revenue over the original bill, Senate Republicans do not propose using the funds to significantly increase the affordability of coverage for low- and moderate-income Americans. And the new version of the BCRA still dramatically cuts and reconfigures the Medicaid program.

The revised bill leaves the original BCRA’s provisions intact, including a phase-out of the ACA Medicaid expansion starting in 2020 and smaller premium tax credits compared to the ACA that make coverage less affordable for low-income people. (For a more complete overview of provisions, see our original post on the CBO score for the bill.)

The CBO estimated in June that the combined effects of these provisions would increase the number of people without health insurance by 22 million by 2026. The coverage losses would be borne disproportionately by people with low and moderate incomes and particularly older adults who purchase their own coverage. The revised bill is unlikely to change those fundamental outcomes.

One of the biggest criticisms of the BCRA is that it would roll back the coverage expansions under the ACA aimed at lower- and moderate-income Americans and give the savings to higher-income people by repealing two taxes that helped fund the expansions. The bill responds to that criticism only by keeping those taxes in place; it doesn’t use the proceeds to make coverage more affordable for less economically privileged Americans.

New Tax Revenue Used for Small Changes

Instead, the bill uses some of that extra revenue to allow people to use health savings accounts (HSAs) to buy health insurance. But HSAs are pre-tax savings accounts whose tax benefits increase with income. Moreover, people with low and moderate incomes are unlikely to have the excess income required to finance an HSA in the first place. This means the tax benefits from this change would flow to higher-income Americans.

The bill provides about $70 billion in new funds for states to reduce premiums through mechanisms like reinsurance. And while this money would certainly help stabilize markets, it’s not enough to make coverage sufficiently affordable for the 22 million people projected to lose health insurance under the BCRA. Moreover, the full amount of the increase appears to be transferred for use in an amendment to the bill, described below.

Similarly the $45 billion proposed in the revised bill for opioid treatment wouldn’t come close to meeting the full health care needs of an estimated 220,000 people with opioid use disorder who are at risk of losing their coverage through the ACA’s Medicaid expansion and the marketplaces.

More Underinsured and Damage to the Individual Market

Another major criticism of the BCRA is that it would significantly increase deductibles and copayments in the individual market. But rather than improving cost-protection, the new bill doubles down by making it possible for people to use premium tax credits to buy even skimpier, catastrophic coverage. While this will result in cheaper plans for healthy people, it would only serve to increase the number of Americans who are underinsured. Yet, because the bill doesn’t make the BCRA’s premium tax credits more generous, it is hard to see how insurance with deductibles that could consume the majority of a low-income family’s income will entice more people to buy it.

But even if there are small gains in coverage under the revised bill, they would likely be more than offset by the damage inflicted on the individual market through an amendment modeled on one by Senator Cruz. By letting states allow insurers to sell ACA-noncompliant policies, the amendment would split the individual market into two pools — one with healthy risks and one with sicker risks. As the insurance industry has already pointed out, this would create the conditions necessary for a true premium death spiral in the individual market, and widespread losses of insurance. To combat this, the amendment appears to borrow the $70 billion in new funds for market stabilization in the revised bill to help states that opted to do this reduce premiums. But based on the U.S. experience with high-risk pools, the funds would likely fall well short of what would be required.

Looking Forward

The ACA has led to millions of people gaining health insurance, many for the first time in their lives. National survey data indicate that this expanded coverage has triggered population-wide declines in cost-related problems getting needed care and reports of problems paying medical bills. But the nation is nowhere near achieving high-quality health care that is affordable for all Americans. In proposing bills that would reverse the small but significant improvements realized so far under the ACA, Senate and House Republicans will only push a better health care system further beyond our reach.

The Golden Rule, With a Twist

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http://www.leadershipdigital.com/edition/daily-operations-leadership-2017-07-13?open-article-id=6864960&article-title=the-golden-rule–with-a-twist&blog-domain=rapidstartleadership.com&blog-title=rapidstart-leadership

The Golden Rule with a Twist

 

 

Why are nurses at Tufts Medical Center striking?

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http://www.masslive.com/news/boston/index.ssf/2017/07/why_are_nurses_at_tufts_medica.html

tufts3.jpeg

 

Fixing Our Most Pressing Health Insurance Problems: A Bipartisan Path Forward

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http://www.commonwealthfund.org/publications/blog/2017/jul/fixing-health-insurance-problems-bipartisan-approach?omnicid=EALERT1241668&mid=henrykotula@yahoo.com

With Senate Republicans mired in seemingly intractable disagreements about how to proceed with health reform—which may very well not be resolved by the latest Senate draft bill, Majority Leader Mitch McConnell suggested on July 6 that a bipartisan short-term fix may be needed for the problems of the individual health insurance market. In fact, opinion polling reveals wide public support for bipartisan health reform. And bipartisanship in health policy is not a fantasy—both the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) and the 2016 21st Century Cures Act passed with wide bipartisan majorities.

How could a bipartisan solution happen? First, it must focus on the individual market, where we face an immediate crisis. Long-term changes to the employer-sponsored coverage market and the Medicare and Medicaid programs, which together cover the vast majority of Americans, can be debated, but nothing needs to change right now. Moreover, sharp ideological divisions between Republicans and Democrats (and within both parties) as to the path forward with respect to public programs and the employer market make short-term consensus unlikely.

Second, we need solutions that can be implemented immediately through existing programs. We do not have time to extensively rewrite federal regulations or implement state-based systems for providing premium and cost-sharing assistance to address pressing problems facing us now.

And third, we may need to accept short-term increases in federal spending to get us through the immediate difficulties, as we have when our country has faced other crises. In the long term, we must cut health care spending growth generally. But in the short term, simply shifting the burdens to individuals who will lose insurance coverage or face much higher deductibles and premiums is not acceptable.

The immediate problem that needs to be addressed is that it appears that individual market coverage will not be available in 40 counties in Nevada, Ohio, and Indiana for 2018. An additional 1,300 counties, representing about one-quarter of marketplace enrollees, may have only one insurer next year. The number of “bare” or single-insurer counties changes from week to week, and these numbers may improve, but it is also possible that more counties will lose insurers by 2018. Moreover, some individual market insurers are requesting double-digit premium increases for 2018 for the second year in a row.

The cause of this crisis is no secret. Insurers and insurance regulators have repeatedly pointed to the regulatory uncertainty driving insurer withdrawals and premium increases. In particular, confusing signals from the administration as to whether it will reimburse insurers for the cost-sharing reductions they are required to offer low-income consumers under the Affordable Care Act (ACA) and enforce the individual mandate has left insurers very nervous about the individual market’s future. Decreased exchange enrollment and a fear of a less healthy risk pool also have insurers feeling insecure.

What can be done? First, Congress should immediately enact a mandatory appropriation to cover the cost-sharing reduction reimbursements through 2020. Not only the major insurer trade organizations, but also the National Association of Insurance Commissioners, the National Governors Association, and the United States Chamber of Commerce have identified this as an urgent necessity. Because the cost of this initiative is already included in the budget baseline, the appropriation would not even have budget consequences.

Second, Congress should ensure coverage for bare counties. The Federal Employees Health Benefits Program (FEHBP) offers private insurance coverage from multiple insurers in every county in the nation. For 2018 and 2019 only, the largest two FEHBP insurers in any county should be required as a condition of continued participation in the program to offer at least one silver-level plan though the federal exchange in all counties that would otherwise be without coverage. These plans should be eligible for premium tax credits and could otherwise charge actuarially appropriate premiums.

Third, Congress should appropriate the short-term premium stabilization funding included in the Senate’s Better Care Reconciliation Act (BCRA), providing $50 billion in reinsurance funds directly to insurers over the next four years. Reinsurance payments of $15 billion for 2018 and 2019 could significantly reduce individual market premiums for those years, as reinsurance did in the first three years of the ACA.

Fourth, Congress should reinstitute the ACA’s risk corridor program for 2018 and 2019 for any county with fewer than two insurers. The Republican’s 2003 Medicare Modernization Act included a risk corridor program to share risk with insurers that experienced unanticipated losses. It remains in place today. Congress essentially defunded the ACA’s risk corridor program in 2015, causing insurers to experience huge losses and driving some to insolvency. The program should be reinstated and funded for 2018 and 2019. Congress should also suspend the ACA’s health insurer tax for insurers that offer individual market coverage in bare and single-insurer counties.

Fifth, Congress should leave the individual mandate in place until it can devise a credible replacement. The House-passed American Health Care Act would impose a 30 percent premium surcharge on people who failed to maintain continuous coverage or allow states to permit insurers to charge higher premiums to such enrollees with preexisting conditions. The Congressional Budget Office (CBO) determined that these penalties would discourage healthy consumers from enrolling, and that allowing health status underwriting would destabilize the market. The CBO also concluded that the Senate’s solution of a six-month lockout period for consumers who lacked continuous coverage would be ineffective. The ACA’s individual mandate penalty is too small, was phased in too slowly, and has not been adequately enforced, but for the time being it is all we have to encourage healthy people to enroll in coverage. Until someone comes up with a better solution, it should be left in place.

Sixth, Congress should rework the premium tax credit formula for 2018 through 2020 to allow younger enrollees to claim more generous tax credits. The BCRA would do this, but would reduce tax credits for older people, discouraging healthy boomers from enrolling. In the short term at least, insurers need all the healthy enrollees they can get, regardless of age.

Finally, every consumer should be able to fully deduct the payments they make to purchase individual market premiums (i.e., not the costs covered by premium tax credits). Self-employed individuals are already allowed to do this. Senate Republicans are reportedly considering legislation that would allow individuals to pay premiums through tax-subsidized health savings accounts, but why require a consumer to go to the trouble of establishing an account and paying associated fees when they could simply pay premiums tax free?

As Senator McConnell has acknowledged, bipartisan action may be needed to address our most pressing problems in the health insurance market. Practical solutions are available. Congress should adopt them immediately and by consensus, and then debate the longer-term future of our health care system.

 

Don’t Assume That Private Insurance Is Better Than Medicaid

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As we recently wrote, it’s better for patients to have Medicaid than to be uninsured, contrary to critics of the program. But is having Medicaid, as those critics also say, much worse than having private insurance?

This idea has become a talking point for conservatives who back big changes to Medicaid, as the Senate health bill proposes. The poor would benefit simply by being ushered off Medicaid and onto private insurance, they write.

But it’s far from proven that Medicaid is worse than private insurance. A lot depends on what kind of insurance is compared with Medicaid, and how they are compared.

Many studies that measure Medicaid against private insurance suffer from the same flaws that compare Medicaid with being uninsured. They’re terribly confounded, and can show only associations, not causation. People with private insurance are healthier and wealthier than those on Medicaid, and in ways not fully controlled for in statistical analyses. These factors almost certainly predispose someone on Medicaid to have worse outcomes than someone with private insurance.

Perhaps the most convincing way to compare Medicaid and private insurance would be with a randomized controlled trial that pits them head to head. No such trials exist. Recall that the Oregon Medicaid study randomly offered, via a lottery, the opportunity for low-income adults to enroll in Medicaid. It did not have another study arm that offered private insurance.

But we do have a decades-old trial that looked at varying levels of cost-sharing: the RAND Health Insurance Experiment. This is relevant because one substantial difference between Medicaid and most private coverage is the level of cost-sharing. Medicaid is nearly free. Most private coverage comes with deductibles and co-payments.

The RAND study randomly assigned 2,750 families to one of four health plans. One had no cost-sharing whatsoever — kind of like Medicaid. The other three had cost-sharing (money people had to pay out-of-pocket for care) at levels of 25, 50 or 95 percent — capped at $1,000 at the time, which is about an inflation-adjusted $6,000 today. This level of personal liability acts like a deductible, making the plan with a 95 percent level of cost-sharing comparable to a “Bronze” plan on the Affordable Care Act’s exchanges today.

The RAND study found that the more cost-sharing was imposed on people, the less health care they used — and therefore the less was spent on their care. The study also found that, over all, people’s health didn’t suffer from lower health care use and spending.

Lower spending and no decline in health — these are the results that everyone cites to justify increased cost-sharing, and to justify shifting people from Medicaid to private plans with high deductibles.

But the results of the RAND study, like so much in health care, are complicated. A deeper dive into the data shows that people decreased their consumption of necessary health care in equal measure to unnecessary health care. As a rule, people are terrible discriminators of what care is needed and what’s not. Since most people under the age of 65 are healthy, even in the RAND study, that doesn’t matter much.

But even if most people are healthy, some are not (and particularly those on Medicaid). In the RAND study, poorer and sicker people — exactly the kind more likely to be on Medicaid — were slightly more likely to die with cost-sharing.

Free care also resulted in improvements in vision and blood pressure for those with low income. As an influential 1983 New England Journal of Medicine paper put it: “Free care does make a difference.”

One limitation of the RAND study is its age. It took place between 1971 and 1982. There have been no studies of cost-sharing to rival it since. Still, the best recent evidence we have is that giving free care to poorer and sicker people improves health and saves lives. It is reasonable to conclude that switching them to a plan with high cost-sharing (even a private plan) would do the opposite.

Some of the more recent studies were nicely summarized in a paper by Katherine Swartz for the Robert Wood Johnson Foundation’s Synthesis project. She found that increased cost-sharing for low-income populations was associated with a shift toward more costly services, like increased emergency room visits because people skipped taking their drugs. She also found that increased cost-sharing affects poor people differently than everyone else, confirming RAND’s findings. A more recent study found that enrollment in plans with high deductibles led to reductions in necessary care, which would have consequences for the poor and sick.

Austin wrote previously herehow increased cost-sharing may lead people to take fewer drugs for their high cholesterol, hypertension and diabetes. In his first Upshot column, Aaron wrote that parents delay taking their children for asthma treatment when cost-sharing rises.

Even small premiums can lead to problems. A $10 increase in monthly Medicaid premiums was followed by a 6.7 percent reduction in Medicaid and coverage of CHIP (Children’s Health Insurance Program) for people just above the poverty line.

Unquestionably, private coverage can work very well for many people. Take us, for instance. The insurance that we each have from our employers is probably better for us than Medicaid would be. Though these plans come with cost-sharing, we have incomes that can handle it. Our plans cover things that Medicaid often does not, like dental checkups.

Our plans have great networks, and they reimburse well for the care we receive. Just like Medicaid enrollees, we also receive support from the federal government, which waives tax collections on dollars contributed to premiums. That tax break is higher than the cost of Medicaid in many cases.

We’re also relatively healthy and would probably be fine on any plan (unless and until our health deteriorates).

But because our plans require considerable cost-sharing, even Medicaid enrollees would struggle on them. More important, neither House nor Senate repeal and replace bills offer poor Medicaid enrollees plans as generous as ours.

The Senate’s health care plan, for example, would offer much less generous plans. A 64-year-old woman with an income of $11,400 would face a deductible of at least $6,000. For her, such a plan is not better than Medicaid; it is most likely much worse if she is also sick. Because of the deductible, the care she’d need would be financially out of reach.

A recent paper in Health Affairs documented that outcomes in Arkansas, which allowed poor people to buy private plans on the exchanges, were similar to those in Kentucky, which expanded access to poor people through Medicaid. But those private plans came with significant cost-sharing subsidies, which would be stripped away by the Senate’s bill. Even so, the evidence did not suggest that the private coverage of Arkansas was better than the public coverage of Kentucky.

There are certainly private plans for poor and sick Americans that are better than Medicaid. But plans with very high cost-sharing — which are the ones being offered in Congress as A.C.A. replacements — are not among them.

 

Five takeaways from the GOP’s healthcare reboot

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Five takeaways from the GOP’s healthcare reboot

Image result for obamacare lite

Senate Republican leaders are pushing ahead with their plan to vote next week on an ObamaCare repeal bill after releasing a revised version of the legislation Thursday to mixed reaction.

For three weeks, leadership has been pulling concerned members into their offices to discuss changes to the legislation. The tweaks released Thursday were aimed at shoring up support within a Republican conference that has been deeply divided over what to do.

Just a few hours after the new bill was released, two senators said they wouldn’t vote for a motion to let the Senate debate the Republican healthcare bill; that means Senate Majority Leader Mitch McConnell (R-Ky.) can only afford to lose one more vote.

Other moderates held their fire on the bill, giving McConnell a chance to win them over in the coming days. And in a big win for GOP leadership, Sen. Ted Cruz (R-Texas) said he would vote for a motion to proceed to the bill, likely neutralizing conservative opposition.

Here are five takeaways from the big unveiling.

It includes a provision key to earning conservative support

An amendment pushed for weeks by Sen. Ted Cruz (R-Texas) could go a long way toward gaining conservative support for the legislation.

A version of the Cruz proposal that was included in the bill would let insurers offer health plans that don’t comply with ObamaCare regulations, as long as they also sell plans that do.

“I think this new bill represents a substantial improvement over the previous version,” Cruz told reporters after leaving a briefing on the draft Thursday.

“If this is the bill, I will support this bill. If it’s amendment, and we lose the protections that lower premiums, my view could well change.”

Another conservative holdout on the bill, Sen. Mike Lee (Utah), worked with Cruz on the amendment, but has not yet said if he supports the bill overall.

“The new Senate health care bill is substantially different from the version released last month and it is unclear to me whether it has improved,” Lee said in a statement.

“I will need time to study the new version and speak with experts about whether it does enough to lower health insurance premiums for middle class families.

Several centrist Republicans have expressed concerns about how this provision would impact people with pre-existing conditions, however, and it’s unclear whether they will accept its inclusion.

The bill would also create a fund to help insurers cover people with expensive medical costs, but it’s unclear if that will be enough to appease moderates.

Medicaid cuts are largely kept in place.

The updated legislation left the deep Medicaid cuts from the first version of the bill essentially unchanged, which could be a big problem for moderate GOP senators like Rob Portman (Ohio), Shelley Moore Capito(W.Va.) and Lisa Murkowski (Alaska).

The legislation would put a cap on federal Medicaid reimbursement for states, dramatically changing the program from an open-ended entitlement. It would end ObamaCare’s increased funding for states to expand Medicaid by 2024, and cut the rate of inflation.

Taken together, the bill would cut $772 billion from Medicaid funding over a decade and result in 15 million fewer people enrolled, according to the Congressional Budget Office.

Medicaid has always been one of the thorniest issues for Republicans to navigate during ObamaCare repeal. Twenty GOP senators represent states that expanded Medicaid. Since the original legislation was released in June, some of those senators have said the Medicaid cuts are their top reason for opposing the bill.

Murkowski as recently as Wednesday had argued that Medicaid reforms should be handled separately from the legislation repealing and replacing ObamaCare.

The lack of major revisions to the Medicaid provisions has already cost GOP leaders the support of Sen. Susan Collins (Maine), who announced she wouldn’t support a procedural motion to allow debate on the bill.

By keeping the cuts in place, McConnell is banking on moderates flipping to “yes” without their No. 1 priority being addressed.

Sen. Dean Heller (R-Nev.) previously said he wouldn’t vote for the bill in its current form, citing the phase-out of extra federal funds for Medicaid expansion as a main concern. Heller on Thursday said he was undecided about moving to proceed. Portman also said he was undecided on the motion to proceed.

The bill includes more money to combat the opioid crisis.  

Originally, the Senate healthcare bill included $2 billion to help combat the opioid crisis, a far cry from the $45 billion Sens. Portman (R-Ohio) and Capito were pushing for.

The new version has exactly that: $45 billion.

But that doesn’t mean the funding will be enough money to win their support. On Thursday, neither senator would say whether they would support a motion to proceed to the bill.

In a statement, Portman said, “I opposed the last draft of the Senate health proposal because I had concerns about the measure’s Medicaid policies, especially those that impact drug treatment for those suffering from addiction.”

Ohio Gov. John Kasich (R) has called for a bipartisan compromise on healthcare and has also urged Portman not to be won over by minor concessions.

“I told him, ‘If they hand you a few billion dollars on opioids … that’s like spitting in the ocean,’ ” compared with the billions the bill would cut from Medicaid, Kasich told reporters last month.

Previously, Capito indicated bolstering the opioid fund probably wouldn’t be enough to garner her support.

“More opioid funding would be very good and very beneficial, but the core for me is the Medicaid provision,” Capito said.

She added: “If you can’t access the treatment, it’s not going to do you any good.”

The bill keeps ObamaCare taxes on high earners.

Republicans reversed from their initial draft and decided to keep ObamaCare’s taxes on high earners.

The bill will keep ObamaCare’s 3.8 percent net tax on investment income and a 0.9 percent payroll tax on individuals making more than $200,000.

The legislation also keeps an ObamaCare rule that prevents insurance companies from writing off compensation that they pay their executives.

The initial draft scrapped all ObamaCare taxes, including those on high earners.

Sen. Bob Corker (R-Tenn.), who pushed McConnell to keep the taxes on high earners, said many senators had an issue with giving rich people a tax break while reducing subsidies for low-income people.

“I think that was something that was felt by many, many, many people in our caucus,” Corker told reporters Thursday.

The measure still repeals other ObamaCare taxes that Republicans say directly impact consumers and drive up premiums, including taxes on the medical device and prescription-drug industries.

Much of ObamaCare would remain.

The bill probably can’t escape the “ObamaCare lite” moniker.

It keeps the structure of ObamaCare’s tax credits to help lower income Americans afford insurance in place, though they would be less generous. A tax on high earners would remain. In short, it’s not a straight repeal of the law.

This means getting Sen. Rand Paul’s (R-Ky.) vote is likely out of the question. Previously, he’s suggested changes that haven’t made it into the bill, such as eliminating a stability fund, repealing more ObamaCare taxes and dropping the continuous coverage provision.

“The thing is that I thought we were pretty clear,” Paul said after the closed-door GOP meeting. “We promised to repeal ObamaCare, this frankly doesn’t repeal ObamaCare. It keeps the subsidies, it keeps the taxes, it keeps the regulations. I think we’re going back on a promise.”

When asked if this bill was worse than ObamaCare, Paul replied, “yes.”