After weeks of secret deliberation that has irritated many of its members, the Senate’s Republican leadership is expected on Thursday to finally release its version of the American Health Care Act, a proposal for repealing and replacing the Affordable Care Act. The working plan, by all accounts, is to rush the proposal, which would restructure about 18 percent of the entire US economy, toward a pre-July 4 vote.
If the proposal can win over at least 50 of the 52-member Republican Senate majority, and can then be reconciled with a House-passed bill that it is expected to differ in numerous major ways, the GOP would be within striking distance of its long-cherished goal of eliminating the Affordable Care Act.
Of course, those are two very big “ifs.”
The intense secrecy of the bill’s drafting has made it difficult to get Republican senators to say definitively where they stand on the proposal, for the understandable reason that they simply don’t know for sure what’s in it. That will change today, with Senate leaders expected to brief their members on its contents at 9:30 in the morning, with a public release scheduled for later in the day.
While nothing is for sure until there is actual legislative language available, some details differentiating the Senate’s version of the bill passed in the House have trickled out to various media outlets following the debate. The differences are key because they highlight the areas in which the two chambers would have to reach compromise if the Senate manages to pass its version of the bill.
Here are a few main areas where the bills are expected to differ.
Medicaid: While both the House and Senate aim to roll back the ACA’s expansion of Medicaid coverage, which was alone responsible for millions of formerly uninsured Americans gaining coverage, they take somewhat different approaches toward a similar goal.
Both would phase out the expansion, which was adopted by more than half of the states and allowed them a very generous federal match of more than 90 percent of costs for previously ineligible beneficiaries. Both would also convert the program from an open-ended entitlement to a capped block grant to the states.
The Senate proposal would reportedly seek a longer phase-out period than the House bill. However, it would ultimately cut spending on the program by even more than the House bill, because it is expected to propose tying the annual budget increase to a rate of inflation that grows much slower than the actual rate of inflation experienced by Medicaid.
Subsidies: As part of its goal of achieving universal health insurance, the ACA tried to make everyone living at or below the federal poverty line eligible for Medicaid, and then subsidized premiums for people living at between 100 percent and 400 percent of the poverty line.
The House version would scrap that system, providing age-based subsidies to all Americans regardless of their income level. The proposal has come under withering criticism because it would make insurance coverage prohibitively expensive for low-income individuals.
The Senate version is said to retain the ACA’s program of subsidies based on income level, though the amount of the subsidies is as yet unclear. The top income level at which subsidies are available would reportedly drop from 400 percent of poverty level ($98,400 per year for a family of 4) to 350 percent of the poverty level ($86,100 per year for the same family.)
Abortion: The House version of the bill contains very strong restrictions on the use of federal funds to pay for abortion. It also cuts off federal funding to Planned Parenthood, the bogeyman of the pro-Life movement.
The Senate version may contain some language aimed at restricting abortion funding, and it is expected to include a restriction of support for Planned Parenthood. However, it is not clear that the chamber’s complex reconciliation rules -- the provision in the Senate’s rules that is allowing the GOP to try to pass this bill with a bare majority and immunity to a Democratic filibuster -- will allow this kind of a change. The issue is said to be in the hands of the Senate parliamentarian.
Waivers: A key element of the House bill is a provision that allows states to seek waivers for many of the requirements put in place by the ACA, such as minimum benefits that must be offered by any insurer selling plans that can be purchased with federal subsidy dollars. Others include limits on how much more people can be charged for coverage if they are older or have pre-existing conditions.
This is a major point of contention with Democrats opposing the bill since expert analysts, including the Congressional Budget Office, believe it will result in millions of older, poor, and sick Americans being priced out of the individual health insurance market.
The Senate is handcuffed by the reconciliation rules, which makes it difficult to use the process for major rule changes. However, the idea appears to be that the Senate will achieve many of the same goals as the House waiver system by expanding a relatively narrow window for exemptions that are built into the ACA already.
Taxes: Like the House, the Senate is expected to push for repeal of tax increases that were put in place to fund the ACA. One exception is that the Senate version may leave the so-called “Cadillac tax” on high-value employer-sponsored health insurance plans. However, the implementation date may be pushed so far into the future that its eventual implementation is in doubt.
Cost-sharing reductions: In a major departure from the House version of the bill, the Senate is expected to propose a two-year extension of cost-sharing reduction payments to insurance companies that sell plans on the ACA’s insurance exchanges. Doubts about the future of these payments, which were designed to help offset the cost of providing below-market rate premiums for low-income consumers, has led many insurers to withdraw their plans from the exchanges, severely limiting, and in some cases eliminating, options for people seeking insurance.
The House version of the bill does not include CSR funding. The House is currently suing the executive branch, claiming that the payments are unconstitutional.
If the Senate manages to pass its version of the bill, when the time comes to try to reconcile its bill with the House, the fight over CSR payments will be intense.