Top takeaways from the week: 1) The Congressional Budget Office released its score of the BCRA on Monday, finding similar coverage losses as the House-passed American Health Care Act (AHCA), and 2) the score prompted Republicans to postpone a vote on their ACA repeal and replacement legislation until after they return from recess.

This week, Senate Republicans continued to negotiate critical pieces of their Better Care Reconciliation Act of 2017 in the wake of the Congressional Budget Office’s (CBO) analysis of the impact of the bill on Monday. Despite aiming for a vote by the Fourth of July recess, Senate Majority Leader McConnell (R-KY) announced on Tuesday that he would not put the bill up for a vote this week, and would instead work to rewrite the bill to assuage concerned Senators, with the goal of advancing the legislation in July. He noted on Tuesday that “Legislation of this complexity almost always takes longer than anything would hope. But we’re pressing on.”

Congressional Budget Office Score –

On Monday, CBO released its analysis of the BCRA, which estimated large coverage losses as well as deficit savings over the period of 2017-2026, raising concerns among Democrats and many Republicans about the bill’s projected impact. Analysis:

Coverage – CBO found that the bill would leave 22 million more Americans uninsured by 2026, with 15 million expected to lose coverage by 2018. While enrollment in Medicaid is expected to fall by 16 percent by 2026, much of the total projected coverage losses is due to the repeal of the ACA’s individual mandate. CBO found that although the BCRA requires insurers to impose a 6 month waiting period on consumers who do not maintain continuous coverage, the waiting period is not sufficient to induce consumers to purchase coverage. In comparison, the House bill was projected to result in 23 million fewer covered lives by 2026.

Deficit Savings – The Senate bill is expected to cut the federal deficit by $321 billion over 10 years, which is much larger than the $119 billion projected for the House bill. The extra savings are largely due to less generous tax credits. BCRA would also reduce the total cuts to the Medicaid program, saving $772 billion over ten years, rather than the $834 billion expected in the AHCA.

Premiums and Out-of-pocket Costs – CBO also found that premiums would increase prior to 2020, but afterward would decrease, relative to projections under current law. However, the share of services covered by insurance would be smaller, resulting in higher out-of-pocket costs for consumers. CBO noted that the average current deductible for a bronze plan (the BCRA’s new benchmark plan) is currently $6,000. Therefore, CBO projects that “despite being eligible for premium tax credits, few low-income people would purchase any plan.”

Medicaid – CBO projected that with less federal reimbursement for Medicaid, states would need to decide whether to commit more of their own resources to fund the program, or to reduce spending, either by cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes, or finding more efficient ways to deliver services.

Meanwhile, Senate Finance Committee Ranking Member Wyden (D-OR) sent a letter to CBO Director Hall requesting that the CBO perform an additional analysis of the bill that would analyze its effects over a 20-year period, rather than the customary 10-year window, arguing that “CBO’s traditional 10-year cost estimate will not fully reflect the impact of this dramatic change to Medicaid.” Press release: Letter:

In response, CBO released a report on the longer-term effects of the BCRA on Medicaid spending on Thursday, finding that Medicaid spending would be about 35 percent lower in 2036 compared with CBO’s extended baseline. Analysis:

Senate Action –

Last week, several Republican Senators, including Sens. Cruz (R-TX), Lee (R-UT), Paul (R-KY), Johnson (R-W), and Heller (R-NV) expressed concern about the bill, pledging that they would not vote for it absent significant changes.

After the CBO released its score on Monday, at least 6 more Republican Senators came out against the bill, and many more remained uncommitted, prompting Majority Leader McConnell to postpone plans to vote on the bill this week until more consensus could be garnered. Sens. Collins (R-ME), Moran (R-KS), Capito (R-WV), Portman (R-OH), and Sasse (R-NE) all cited serious concerns with the bill in its current form, while  Sen. Paul released a letter on Tuesday outlining a list of “policies priorities” he feels would improve the health care system and insurance markets. Press release: Letter:

In response, Senate Leadership has spent much of the week trying to build consensus through amendments and inducements. Potential changes include:

  • Medicaid – Revise the growth rates to limit the reimbursement cuts to states
  • Tax Credits – Amend the subsidies that help consumers afford to purchase coverage
  • Market Reforms – Conservatives have argued for greater flexibility from the ACA’s market rules
  • ACA Taxes – Maintain certain taxes, like the net investment tax, in order to pay for greater Medicaid and tax credit spending
  • Opioid Funding – $45 billion in additional funding for the opioid crisis
  • Health Savings Accounts – Allow consumers to use their HSA dollars to pay premiums
  • Planned Parenthood – Sens. Collins and Murkowski have been reportedly crafting an amendment to restore Planned Parenthood funding

Senate leaders have aimed to circulate a new policy outline on Friday to send to the CBO over the recess, in the hopes of holding a vote when they return the week of July 10.

Governors and State Medicaid Directors have also weighed in, arguing for more time and against drastic changes to the Medicaid program. The National Governors Association (NGA) sent a letter to Majority Leader McConnell on Monday requesting that Congress give governors time to review and react to any health care legislation before proceeding, to “ensure that the bill does not adversely harm the people we were elected to serve.” Letter:

The National Association of Medicaid Directors (NAMD) also released a statement on Monday noting that “Medicaid is complex and therefore demand thoughtful and deliberate discussion about how to improve it…While NAMD does not have consensus on the mandatory conversation of Medicaid financing to a per capita cap or block grant, the per capita growth rates for Medicaid in the Senate bill are insufficient and unworkable.” Letter:

Meanwhile, on June 28, Sen. Shaheen (D-NH) and 20 Democratic cosponsors introduced the Marketplace Certainty Act (S. 1462) which would amend the Patient Protection and Affordable Care Act to improve cost-sharing reduction subsidies. Press release:

House Action –

On Tuesday, Democrats on the House Committee on Oversight & Government Reform released state-by-state reports describing the effects of the Better Care Reconciliation Act on children with disabilities. Press release: Reports:


And on Wednesday, Democrats from the House Energy & Commerce Committee and the Senate HELP Committee released a report outlining the Trump Administration and Congressional Republicans’ “intentional sabotage of the individual insurance markets to justify passage of Trumpcare.” Press release: Report:

Administrative Action –

On June 28, CMS published a document that provides details on cost-sharing reduction (CSR) reconciliation discrepancy files that issuers will send to CMS for the 2016 benefit year. Document: