The Senate and House Similarities:
- Eliminate the ACA’s controversial individual mandate, which required all Americans to have health insurance.
- Eliminate the ACA’s unpopular employee mandate, which required most employers to offer employees health insurance.
- Enable payers to implement age-based pricing determinations for health insurance.
- End the ACA’s Medicaid state-expansion and reduces overall Medicaid funding (although the Senate version proposes a deeper rate than the House version).
- Enable states to waive the ACA’s requirement that payers cover the following 10 essential health benefits: 1) ambulatory patient services; 2) emergency services; 3) hospitalization; 4) maternity and newborn care; 5) mental health and substance abuse; 6) prescription drugs; 7) rehabilitative and habilitative services; 8) laboratory services; 9) preventive and wellness services and chronic disease management; 10) some pediatric services.
- Defund Planned Parenthood for one year.
- Repeal most of the ACA’s taxes.
- Continues the ACA’s policy that enabled children to remain beneficiaries of their parents’ health plans until age 26.
- Tax Credits: The Senate version lowers the income eligibility level for tax credits. The House version fixed tax credit eligibility to age.
- Pre-Existing Conditions: The Senate version maintains the ACA’s requirement that payers cover individuals with pre-existing conditions without charging these individuals higher rates. The House version would enable states to allow payers to opt out of mandating coverage for preexisting conditions. In lieu of this requirement, the House version would provide states funding to establish high-risk pools to cover individuals with pre-existing conditions.
The BCRA would overhaul the current Medicaid expansion system by phasing out the Federal Medical Assistance Percentages (FMAP) to states by 15 percentage points between 2020 and 2023 (90-percent funding in 2020 to 75-percent funding in 2023). In 2024, FMAP reductions would continue until they matched the state rate for other benficiaries, which is, on average, 57 percent.
Traditional Medicaid Funding
While both the Senate and House versions would reduce federal funding to the Medicaid program, the Senate version replaces the program’s current open-ended entitlement with individual beneficiary caps. Beginning in 2020, states would be eligible to receive federal block grants instead of the proposed funding cap if they meet specific requirements and agree to cover 14 essential services. States may also begin to implement optional work requirements for non-disabled, non-elderly, and non-pregnant beneficiaries.
Looking Back—and Ahead
The ACA’s collapsing state exchanges shows just how difficult and costly it is to expand and ensure coverage. Theoretically, the ACA’s individual and employer mandates would alleviate the burden to payers by requiring young and healthy Americans to buy health insurance. The ensuing support from these mandates did not come through as expected, causing payers to leave state exchanges—and leaving many Americans with little or no insurance options. Coverage and care are two critical—but distinct—components to healthcare. Policymakers’ efforts to provide insurance to all Americans is misguided if that coverage does not equate to quality care.
The Congressional Budget Office, which provides price estimates to legislation, is currently assessing BCRA. This cost assessment will shed more light on who would pay more or less for premiums and how the bill would affect the market stability of insurance companies.
Healthcare reform is a complex and complicated process that will impact the way we provide and receive healthcare. A lot needs to happen before we see these changes—including enough support among Senate Republican to pass BCRA. The process continues to be partisan and Republicans are finding that repealing and replacing the ACA is not easy. Stay tuned.