As the July issue of Nashville Medical News was going to press, the U.S. Senate had just decided to defer a vote on their Obamacare 'repeal and replace' strategy amid dissension in the ranks. The Senate version came in the wake of national outcry following the U.S. House of Representatives narrow passage of the American Health Care Act (AHCA).

If Mitch McConnell is successful in moving "The Better Care Reconciliation Act of 2017" forward, he will have to find a way to simultaneously appease conservative senators who believe BCRA doesn't go far enough and moderates who believe it goes too far in replacing the Affordable Care Act. Adding to the difficult balancing act is a Congressional Budget Office score that estimates BCRA would result in millions of Americans losing coverage over the coming years, which should make the holiday recess with constituents fun. With no Democrats expected to support the bill, McConnell cannot afford to lose more than two GOP votes.

If McConnell rallies the troops through ongoing negotiations to the legislation, the bill must then go back to the House. Differences in strategy between the Senate and House versions of healthcare, coupled with deep ideological differences among Republican lawmakers, likely signals an uphill climb to find consensus.

Key points to the Senate draft (as of press time) included:

• Tax credits based on income will continue to help individuals purchase insurance as with ACA. Currently, credits are available for Americans making up to 400 percent of the federal poverty level. In the Senate bill, that cap would be at 350 percent of FPL after 2020. In the House AHCA bill, credits were tied to age. The Senate version still has an age factor, but income is weighted more heavily.
• The Senate bill rolls back the significantly higher federal match rate that was part of the ACA Medicaid expansion program for those making 100-138 percent of FPL. No one would be allowed to join expansion beginning in 2020, and the federal funding of the expanded rolls would be phased out over four years beginning in 2020. By 2023, the additional federal funding would be eliminated, which could lead states to contract Medicaid rolls.
• Those who fell in the 'donut hole' after the Supreme Court ruled states couldn't be forced to expand Medicaid coverage would be eligible for tax credits.
• While the tax credit for individuals is more generous in BCRA than the AHCA, Medicaid spending growth down the line would be more severely impacted by the Senate version. Both bills have a per capita Medicaid spending limit, but the Senate bill shifts the calculation from the consumer price index for medical care, which is more generous, to the lower general CPI rate after 2025.
• States won't be allowed to 'opt out' of covering pre-existing conditions but can request a waiver for covering the 10 essential health benefits under ACA.
• The bill allows for funding of a federal reinsurance program to stabilize the individual insurance market on a temporary basis.
• Most ACA taxes would be rolled back, and the bill eliminates the individual mandate to buy coverage.

What's at Stake?

Last month icitizen released poll results gauging reaction to the proposed AHCA legislation. Nearly 65 percent of American adults polled said they would be less likely to reelect their U.S. Senator or Congress member if he or she votes to enact the AHCA.

The online survey of 1,290 U.S. adults found more than 6 in 10 Americans believe the AHCA would have a negative effect on their household.

"Interestingly, a quarter (25 percent) of Republicans believe that AHCA will have a negative effect on their household, along with 85 percent of Democrats. Only 45 percent of Republicans believe the AHCA will have a positive effect on their household, a full 19 percent drop from last month's icitizen poll," said Cynthia Villacis, icitizen's director of Polling.

Pessimism over healthcare reform measures is more pronounced among several groups. Belief in the negative effect of AHCA is especially strong among women under 50 (75 percent), racial minorities (68 percent) and Independents (70 percent).

"This poll demonstrates that one month since the House's passage of the AHCA, the public remains pessimistic about the new healthcare legislation. Republicans' opinion remains mixed, suggesting that advocates of the AHCA should consider reforms to the bill that would unify the party," noted Villacis. With the 2018 midterm elections looming, members of Congress from both sides of the aisle must be prepared for Americans to hold them accountable for their vote on the AHCA."

Whether or not the Senate version is received more warmly outside of the Beltway remains to be seen. Information on AHCA, the Senate bill, and reaction from a variety of stakeholders are available online.

Related Link:
icitizen

Comment from the August 2017 print edition of Nashville Medical News:

To Whom It May Concern:

Just read your July issue and wanted to make an observation. In your article, "Reforming Healthcare Reform," I read much of the same misinformation being announced by the media and state and federal legislators. There were several areas, but I will stick to one. The graphs and statements made toward the end of the article are misleading. I realize you did not conduct the survey, but you are using it as a platform for your opinion. The graphs suggest that 63 percent of U.S. adults believe AHCA will negatively impact their household. 63 percent of U.S. Households would total 200,970,000 individuals, less those under 18 years of age. Even then, that is a lot of citizens, especially when ACA directly affects only 51,000,000 total individuals. This number includes the uninsured and those currently covered under ACA exchange programs. The second graph is the most telling. 64 percent of U.S. adults say they are less likely to re-elect their representatives if they vote for AHCA. Since ACA and AHCA directly affects 51,000,000 people where did 64 percent of the population get the notion that AHCA would affect ... well everyone? Probably from articles like the one you and others publish. Legislators are not trying to fix the problem, as if they have a clue what the problem is, they are trying to get re-elected. They take the attitude that whoever fixes the problem must get credit for doing so. I take the attitude that the only way to fix the healthcare cost crisis is for somebody to make less money.

The problem at hand has been handled incorrectly from the beginning by both parties and incorrectly followed and reported by the media. Every aspect of every solution put forward is connected to financing. There is nothing of significance related to behavior and responsibility (that has) been placed on the table, other than work requirements if enrolled in Medicaid, which brought jeers of boos from the crowd. These are the aspects at the heart of the disagreement. The folks we talk to are not concerned about the negative impact of reforming ACA. They are concerned about the real issue - Medicaid expansion.

Bob Shupe, REBC^®, CEO, ESP, LLC

Editor's Note: We are committed to sharing multiple viewpoints regarding healthcare finance and delivery reform. We have reached out to Bob Shupe - who leads Brentwood-based ESP, a company of fee-based health management consultants working primarily in the public entity sector - and plan to circle back to him and to others in the coming months to share frontline client experiences and thoughts on improving the viability and sustainability of healthcare in America.