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To the Senate We Go: What's Going On With Health Care Behind Closed Doors?

On May 4, the U.S House of Representatives went to the floor for a second time to vote on the American Health Care Act (AHCA) -- just 6 weeks after House Speaker Paul Ryan pulled the bill for not having enough Republican support and conceding that “[w]e’re going to be living with Obamacare for the foreseeable future.”  Needing 216 votes to pass the House, the AHCA passed by a narrow margin of 217-213, with a vote along party lines.  

After passing the House, the bill headed off to the Senate, where expectations as to timing are slow and steady.  The Senate is set on writing their own bill -- not on making revisions to the House's version.  According to Bloomberg, the rewritten bill will carry less of a punch than the House bill, with a repeal effective date of 2020.  In 2018 - 2019, the bill will take action to stabilize the individual marketplaces.  But, most of the bill's changes -- or rewrites -- are happening behind closed doors, with sequestered Senators.

So so we know anything else about the Senate's health care bill?

The Congressional Budget Office Score

On May 24, 2017, the Congressional Budget Office released its report (CBO Score) on the House's AHCA bill. The CBO Score indicated that 14 million more people would be left uninsured if the House version were passed than if the Affordable Care Act (ACA) stayed in place.  That number would rise to 23 million more in 2026.  Losses in coverage would primarily impact those on Medicaid, those on individual policies, or those with pre-existing conditions who do not maintain consistent coverage.  

Older individuals will pay up to 10 times more for premiums than young adults, and more than 9 times than ACA premiums. The CBO Score continues by stating that over time, it will be difficult for less healthy people -- including individuals with pre-existing conditions -- to afford insurance as the premiums will continue to increase.

Nonetheless, the House bill still achieves enough deficit savings -- $119 billion -- to allow the House bill to proceed to the Senate for consideration.

As reported by Time, Republican Senators have conceded that the release of the CBO Score has complicated their effort to come to agreement on amendments to the AHCA, and repealing the ACA. However, as reported by NBC News, Senator Ted Cruz (R-Texas) stated, "[t]he CBO score of the House is one factor, but I think in any universe the Senate bill will be significantly different from the House bill."  In other words, that's not the Senate's CBO Score.  However, the Senate must take the points the CBO raised and consider them in their re-write.

Hot Buttons for Contention

Medicaid is one of the largest points of contention, bigger than pre-existing conditions.  With approximately 20 Republican Senators coming from states with Medicaid expansion, the House's version of the AHCA will have great difficulty passing the Senate. However, that does not mean that re-drafting is a slam dunk.  

Republican Senators cannot decide whether Medicaid expansion should be curtailed or further expanded. One specific point of contention facing the Senators is whether to convert open-ended federal funding for beneficiaries into a system of capped payments to the states, thus affecting approximately 70 million Americans.  This is a difficult approach as states distribute monies differently based upon population health, provider markets, policy choices, and other factors, as reported by Modern Healthcare.  

Another urgent challenge for Senators is to determine a solution to stabilize the individual insurance markets, which are headed for trouble as insurance companies are announcing plans to pull out or to increase premiums in 2018. Senator Lamar Alexander (R-TN) has suggested that a temporary solution may include supporting the individual markets until the Republican plan is in full force, hence the 2020 effective date of the repeal.  Thirteen Senators have begun to work with large insurance carriers -- including Aetna, Humana, and UnitedHealth Group -- all of which have reduced their participation in the Exchanges, as Senators are seeking input from the industry on stabilization.

Senator John McCain (R-Arizona) laid out his concerns, rather succinctly, to NBC News, which perhaps sums up where the Senate currently stands on the repeal of the ACA, and the amendment of the AHCA, all to be passed by September 30 fiscal year:

Here's the reality: We've got eleven weeks between now and the end of September . . . . We've got the repeal of Obamacare, we're talking about tax reform, we're talking about a defense bill, we're talking about ... there's about three other things — a looming debt limit. How do you pack all that in? And so far, I've seen no strategy for doing so. I'm seeing no plan for doing so.

In an exclusive interview with Reuters, U.S. Senate Majority Leader Mitch McConnell said, "I don't know how we get to 50 [votes] at the moment.  But that's the goal.  And exactly what the composition of that (bill) is I'm not going to speculate about because it serves no purpose."  Further, McConnell stated that expectations for tax legislation passage were "pretty good," although difficult, but "not in [his] view quite as challenging as healthcare."

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