The Republican Senate’s first attempt to revise its proposed healthcare bill, the Better Care Reconciliation Act (BCRA) of 2017—which would replace the Affordable Care Act (ACA), didn’t have enough support to proceed to a vote. GOP Senators made more revisions and presented them on July 13. But within a few days, four GOP Senators announced that they would not vote for the revised bill, causing it to fail yet again.
Here’s a look at four changes in the second round of revisions that just weren’t enough to muster up enough votes.
Sen. Ted Cruz's amendment. This revision would have allowed insurers offering Obamacare plans to also offer cheaper, bare-bones policies that didn’t include coverage for the ACA’s essential health benefits such as maternity care. “This gave in to conservative holdouts who believe that the insurance marketplace is too costly for some to purchase insurance,” says Timothy Hoff, professor of management, Healthcare Systems and Health Policy, D’Amore-McKim School of Business. “However, it would have created two separate risk pools for insurance companies to deal with—one that is healthy and just wants cheap, more catastrophic coverage and another comprised of sicker individuals who need more comprehensive insurance and want protection from large out-of-pocket costs. If passed, individuals with pre-existing conditions would not have been able to find affordable insurance—just like before the ACA.”
A $45 billion fund for opioid addiction treatment. “While this is a huge increase from the first Senate bill, which was just $2 billion, it was not nearly enough to address what is perhaps the biggest public health epidemic of our time,” Hoff says.
Health savings accounts (HSAs), which are accrued from pre-tax dollars, could be used to pay for health insurance premiums. This revision would have changed the conditions that created employer-based healthcare in the United States, and could have had negative repercussions. “Under the current system, only employers—not individual employees, receive tax advantages for paying health insurance premiums,” says Kevin Fitzgerald, a partner in the law firm Foley & Lardner LLP, an international law firm with a prominent healthcare and health insurance practice. “If employees could use pre-tax dollars for premiums, employers might decide to raise salaries and cut back on health insurance offerings (particularly in the absence of an employer mandate and related penalties), since employees would be able to achieve tax efficiencies by using an HSA account.”
Says Hoff, “This is a nod to conservative Republicans because the more affluent are likely the ones who would benefit most as poorer citizens often have little additional income to put into these accounts to begin with, and the pre-tax savings accrues most to those in higher income tax brackets. Many have labeled it as just another tax shelter for wealthy Americans.”
Catastrophic health plans would be offered and people could be eligible for tax credits to help pay for them. Insurers can already offer catastrophic health plans to certain consumers, but making them available to all consumers could contribute to adverse selection. “The healthy would purchase low-cost policies, and the sick would opt for full ACA-compliant policies,” Fitzgerald says. “That would likely make comprehensive coverage increasingly expensive.”
“With the exception of the Cruz Amendment, which would represent a significant change to the status quo and to previous House and Senate proposals, many of the changes in the most recent draft seemed more political than policy-driven,” Fitzgerald concludes. “Senate leadership was seeking votes from previous holdouts, including Senators Cruz and Mike Lee, and also from moderate Senators who were concerned about opiates or the optics of a large tax cut for higher-income taxpayers at the same time Medicaid was cut.”
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.