Your guide to what the BCRA would actually do—and the 3 big roadblocks to its passage

Topics: Public Health, Providers, Politics and Policy, Federal Government, Health Care Legislation, Health Care Reform, Insurance, Medicaid, Exchanges

By Heather Bell, managing editor

The Senate Thursday released its long-awaited health reform draft bill, but GOP senators say more changes will be needed to secure the 50 votes needed to pass the bill in the Senate.

What the Senate bill would do

Among other things, the draft bill, called the Better Care Reconciliation Act of 2017, would eliminate most of the Affordable Care Act's industry taxes and taxes on those with high incomes, which currently help fund subsidies intended to make coverage more affordable for low- and middle-income U.S. residents. As a result, it would lead low- and middle-income residents to pay more out-of-pocket for less comprehensive plans.

Check out our chart for a comprehensive breakdown of how the BCRA compares with the ACA and AHCA >>>

In addition, the Senate draft bill would change the actuarial value for benchmark plans from one that, on average, covers 70 percent of an enrollee's costs to one that, on average, covers 58 percent of an enrollee's costs. And, according to David Nather and Sam Baker in Axios' "Vitals," the draft bill would eliminate the ACA's "affordability test" for employer plans, meaning workers would no longer be able to get a tax credit to purchase non-employer health care if the plans the employer offers are too costly or not comprehensive enough.

The Senate bill would also eliminate the "coverage gap" in states that did not expand Medicaid under the ACA. Under the ACA, only people between 100 and 400 percent of the federal poverty line are eligible for tax credits—as lawmakers at the time the ACA was drafted had expected that all states would be required under the law to expand Medicaid, and thus provide coverage for those earning less than the poverty line. But when the Supreme Court determined that the ACA's Medicaid expansion must be voluntary for states, some low-income people in non-expansion states found they earned too much money to qualify for their state's Medicaid program and not enough to qualify for tax credits under the ACA.

Under the Senate bill, everyone below 350 percent of the federal poverty level would qualify for tax credits. However, some experts questioned how helpful the change would be for people currently in the gap, as the bill's subsidies to help individuals purchase insurance would be less generous—meaning even people eligible for the subsidies might be unable to afford coverage.

The three big roadblocks in the bill's future

Senate Majority leader Mitch McConnell (R-Ky.) reportedly still plans to bring the bill to floor for a vote before the July 4 recess.

However, Senate Republicans face three main roadblocks to bringing the bill to a vote:

  • The Senate must wait to vote until it has an official CBO score, which is expected to come as early as next week;
  • The Senate Parliamentarian has yet to rule on whether specific measures—such as those related to the age-band restrictions, the ACA's 1332 waivers, and abortion—meet requirements to be considered under the reconciliation process; and
  • It does not appear that McConnell has secured the 50 votes necessary to pass the bill.

Conservative GOP Sens. Ted Cruz (Texas), Mike Lee (Utah), Ron Johnson (Wis.), and Rand Paul (Ky.) in a statement said they do not support the bill in its current form, but "are open to negotiation and obtaining more information before it is brought to the floor." Paul separately said the draft bill contains too many ACA regulations and maintains the law's structure for tax credits.

Some moderate senators, such as Sen. Susan Collins (R-Maine), also expressed concerns with the bill. Nather Baker in Axios' "Vitals" wrote some key sticking points for moderates could include the significant Medicaid cuts and low funding for opioid misuse programs. The Senate draft bill in 2018 would provide $2 billion for opioid misuse efforts, but Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W. Va.) have reportedly asked for $45 billion over a decade.

However, Vox's Dylan Scott suggests that McConnell purposefully crafted a draft bill that would "give both his conservative and his moderate senators some wins and some losses," adding, "If senators decide that the most important thing to them is saying they repealed Obamacare, there is a path to yes for all of them."

As Sen. John Thune (R-S.D.) told reporters Thursday, "There are some things we've said all along that are dialable, that we can hopefully tweak a little bit before it comes to the floor."