Top takeaways from the week: 1) Senate Republicans released an updated version of the Better Care Reconciliation Act and 2) Senate leadership is hoping to bring the bill to the floor next week, with an updated CBO score expected on Monday, and 3) Democrats are pushing for bipartisan fixes to the ACA, having released a number of bills and proposals this week.

Today, Senate Republicans released the latest version of their ACA repeal and replacement bill, the Better Care Reconciliation Act (BCRA), in the hopes that the updated version would better appeal to increasingly skeptical members. Congressional Leaders are aiming to bring the bill to the floor next week, in the hopes of moving onto other issues that have been held up by healthcare reform. In announcing the cancellation of the first two weeks of the Senate’s August recess period on Tuesday, Senate Majority Leader McConnell (R-KY) noted, “We’re going to do health care next week. Then we’re going to turn to other issues.”

Senate Action –

The Senate Budget Committee released updated text for the Better Care Reconciliation Act, which would partly repeal and replace the ACA. The new version of the bill largely retains the same Medicaid reforms, but provides more substantial funding for market stabilization and to combat the opioid epidemic. The bill also includes a placeholder for an amendment introduced by Sen. Cruz (R-TX) that would allow issuers greater flexibility in offering less comprehensive plans. Major changes include:

  • Long-Term State Stability and Innovation Fund. Provides an additional $70 billion to help cover consumer out-of-pocket costs and market stabilization.
  • Health Savings Accounts. Allows consumers to use health savings account contributions to pay for premiums.
  • Catastrophic Coverage. Consumers with catastrophic coverage are eligible for tax credits, and allows anyone to purchase catastrophic coverage, not just those under the age of 30.
  • Taxes. Retains the net investment income tax, the additional Medicare tax, and the remuneration tax on executive compensation for certain health insurance executives.
  • Medicaid. Revises the DSH calculation and applicability. Allows states to waive per capita caps or block grants in the case of a public health emergency. Also allows states to add the expansion population under the block grant.
  • Opioid Funding. Provides an additional $45 billion for substance abuse treatment and recovery grants and research.
  • Cruz Amendment. Sen. Cruz’s amendment would allow health insurance issuers to offer non-ACA compliant plans off the health insurance marketplaces as long as they also offer ACA-compliant coverage. Provides funding to issuers to cover the cost of covering high-risk consumers enrolled in ACA-compliant coverage.

A comparison chart featuring a side-by-side of the current BCRA, the previous version of the BCRA, and the House-passed American Health Care Act (H.R. 1628) is attached. Senate Budget Committee Press release: Section-by-section:  Summary of Cruz Amendment: Bill text:

The Congressional Budget Office is expected to provide an analysis of the updated BCRA – both with and without the Cruz amendment – on Monday.

At least 10 Senate Republicans had expressed significant reservations about the previous version of the BCRA, either due to the CBO’s projections of high coverage losses and out-of-pocket costs or because the BCRA doesn’t go far enough in repealing the ACA. Initial reactions from Senate Republicans today did not bode well for the bill’s future; Sens. Paul (R-KY) and Collins (R-ME) said they would vote against allowing debate to even start on the bill, while several other Republicans, including Sens. Flake (R-AZ), Portman (R-OH), Lee (R-UT) and Hoeven (R-ND) said they were undecided. Other Senators, like Sens. Grassley (R-IA) and Capito (R-WV) expressed concern that the Cruz amendment would make it harder for people with pre-existing conditions to get covered.

Additionally, key stakeholders, such as AHIP and the Blue Cross Blue Shield Association (BCBSA) have written to Congressional Leaders expressing concern with Sen. Cruz’s proposed amendment. AHIP noted that “this proposal would fracture and segment insurance markets into separate risk pools and create an un-level playing field that would lead to widespread adverse selection and unstable insurance markets” while BCBSA noted the amendment “is unworkable as it would undermine pre-existing condition protections, increase premiums and destabilize the market.”

Yesterday, Senate Majority Leader McConnell pleaded with Senators to allow the bill to proceed to debate, noting, “I’m sure members will have other good ideas…and I hope they will offer them…but if the Senate is prevented from even proceeding to the bill, none of us will have an opportunity – not Republicans, not Democrats, not anyone.”

Sen. Graham (R-SC) has already announced a proposed amendment to the bill, which would block grant current ACA subsidy funding – an estimated $116 billion in 2016 – to the states to use for health care spending. The amendment would also repeal the individual and employer mandates, maintain ACA requirements for pre-existing conditions, and would retain all of the ACA taxes, except the medical device tax. The bill would provide additional Medicaid flexibility for states. Press release:

Meanwhile, on Monday, Senate Minority Leader Schumer (D-NY), Minority Whip Durbin (D-IL), Senate HELP Committee Ranking Member Murray (D-WA) and Sen. Stabenow (D-MI) sent a letter to Senate Majority Leader McConnell (R-KY) urging him to “focus on immediately advancing policies to provide stability and certainty to the health insurance markets” and highlighting several bills previously introduced by Democrats to address these issues. Letter:

Additionally, Sen. Warner (D-VA) and 9 Democratic cosponsors introduced the States Achieve Medicaid Expansion (SAME) Act  (S. 1545) yesterday, which would provide the same level of federal matching assistance for every state that chooses to expand Medicaid coverage to newly eligible individuals, regardless of when such expansion takes place. Sen. Warner also introduced, along with Sens. Manchin (D-WV), Heitkamp (D-ND) and King (I-ME) the Commonsense Competition and Access to Health Insurance Act (S. 1546), which would provide greater flexibility in offering health insurance across state lines. Press release: Summaries: and

Also yesterday, Sen. Broad (D-OH) released a report outlining the consequences of repealing the ACA for Ohio’s rural communities. Press release with link to report:

House Action –

On July 12, Reps. Schrader (D-OR), Bera (D-CA), Kuster (D-NH) and seven other Democratic representatives released a five-part plan to improve upon the ACA and stabilize the individual marketplace. The plan would protect plans for people with pre-existing conditions, keep costs down for lower income families, promote enrollment and ensure people pay their fair share, create more affordable insurance options, and would make other technical changes and improvements to the law. Press release:  Plan:

Administration Action –

On Monday, CMS announced that 141 individual market qualified health plan (QHP) issuers submitted initial applications to offer coverage using the federally-facilitated marketplace in 2018, a reduction from the 227 issuers that submitted an initial application in 2016. Yesterday, CMS released an updated map of projected issuer participation in the exchanges in 2018. Press release: HHS Secretary Price statement: Map:

On Tuesday, CMS announced the approval of Alaska’s section 1332 Innovation Waiver, which would establish the Alaska Reinsurance Program for 2018 and future years in an effort to stabilize the individual healthcare market in the state. Alaska is the second state to receive approval for a 1332 waiver. CMS Press release:  HHS Secretary Price Press release: Senate HELP Committee Chair Alexander (R-TN) Press release: Waiver summary:

Yesterday, the White House Council of Economic Advisors (CEA) released its analysis of the Congressional Budget Office’s (CBO) estimate of the Better Care Reconciliation Act (BCRA), arguing that BCRA results in at least $265 billion more federal Medicaid spending between 2018 and 2016. Press release: Analysis:

Today, CMS released guidance on annual eligibility redetermination and re-enrollment for exchange coverage in 2018. Guidance: