Senate Republicans have released a draft version of their bill to repeal and replace portions of the Affordable Care Act (ACA, or “Obamacare”). Here are 10 stray thoughts as we all begin poring over the text.
- The Senate version renames the bill the Better Care Reconciliation Act (BCRA) of 2017. The House version is the American Health Care Act (AHCA) of 2017. The differing abbreviations provide a nice shorthand for distinguishing between the two versions of the bill.
- Those claiming that the BCRA “repeals and replaces” the ACA overstate their case. The BCRA modestly alters the AHCA, which, in turn, modestly alters the ACA. Most changes are highly technical, and many are downright arcane. Neither the BCRA nor the AHCA will dismantle the core structures of the ACA.
- Those bellowing that tens of millions will lose insurance coverage, consigning myriad Americans to sickness and death are also blowing smoke. The dire predictions on coverage compare hazy predictions of hypothetical laws with impossibly optimistic expectations of the current law. And in America, the uninsured have not gone without care, though the financing of that care has been messy. In addition, economic research has established a much weaker connection between coverage and health than intuition might suggest.
- Both the House and Senate bills eliminate the individual mandate that requires Americans to buy health insurance or pay a tax in lieu of coverage. The House bill would replace the mandate with a weaker penalty, thereby destabilizing the ACA’s already unstable insurance markets. The Senate bill would eliminate the mandate without replacing it at all, likely destabilizing things even faster.
- The BCRA drops all ACA taxes except for the “Cadillac Tax” on high-cost insurance plans, action on which has been pushed to 2026. Implementation or elimination of this tax has been pushed back repeatedly. We may have flying Cadillacs before this issue is finally resolved.
- The BCRA phases out the ACA’s Medicaid expansion more slowly than the AHCA and alters the eligibility rules significantly.
- In the Senate version, insurance premium subsidies are a bit larger but cease once households reach three-and-a-half times the federal poverty level (FPL), rather than the House version’s four times the FPL. In addition, in states that did not expand Medicaid, households with income under 100 percent of FPL will be eligible for subsidies, thus filling a gap the ACA left.
- State waivers from ACA provisions are broader in some areas. For example, states can eliminate health insurance exchanges altogether. State waivers are narrower in other areas. The Senate version more clearly retains the ACA’s guarantees for individuals with pre-existing conditions.
- Like the ACA, neither the BCRA nor the AHCA tackles the real problems of American health care. The ACA promised lots of care to tens of millions of newly insured people and quite a bit of free stuff to hundreds of millions of previously insured people. But the law did not appreciably increase the supplies of doctors, nurses, hospital beds, and so forth. Nor did it markedly change how we use those resources. The ACA redistributed care and money from some people to other people. For the most part, the BCRA and AHCA do the same.
- Finally, for the sake of future health care reform, the best outcome in 2017 may be one in which Republicans can claim “We repealed and replaced Obamacare” while Democrats can simultaneously claim, “We saved Obamacare.” Then perhaps we can turn our attention away from insurance technicalities and toward changing how we actually produce care for patients. That will allow us to provide better health to more people at lower cost year after year.
HENRY KOTULA 