National WIC Association


June 26, 2017

ACA Replacement Update

Senate Republicans released a discussion draft of their bill to repeal and replace the Affordable Care Act (ACA) last Thursday morning. Although the draft, entitled “the Better Care Reconciliation Act (BCRA),” differs somewhat from the House-passed healthcare bill, it takes many of its key provisions from the House Republicans’ American Health Care Act (AHCA), which the House passed in May.

The Senate’s discussion draft is similar to the House-passed bill in the following ways:

  • Elimination of the so-called “individual” and “employer” mandates which, respectively, require individuals to purchase health insurance or face a fine and require employers with at least 50 employees to provide health insurance to their employees – this is a key financial underpinning of the ACA allowing millions to access previously unavailable healthcare.
  • Steep cuts (in the hundreds of billions of dollars) to Medicaid that limit its spending in future years – potentially cutting millions of children and adults currently enrolled in Medicaid and reducing services for others. Some 37 million children are currently enrolled in Medicaid.
  • A greater administrative burden on states to administer Medicaid due to the per capita caps established in the legislation.
  • Drastic reductions in the ACA’s open-ended tax subsidies, which would disproportionately impact low- and middle-income Americans.
  • Elimination of ACA’s tax increases.
  • States could receive waivers to opt out of some of the ACA’s consumer protections including provision of “essential health benefits,” including maternity care and mental health services.
  • A ban on funding for Planned Parenthood for one year – affecting the essential primary healthcare services for 2.4 million women.
  • A massive tax cut that would significantly favor higher-income Americans.

The Senate’s bill breaks with the House bill on these:

  • A longer transition period.
  • A three-year phase-out of the ACA’s Medicaid expansion beginning in 2020, compared to the immediate ending in 2020 of the Medicaid expansion called for in the House bill.
  • The exemption of children from the Medicaid block grant option.
  • A lower reimbursement rate for states under Medicaid, which would lead to even deeper cuts on children, people with disabilities, and senior citizens than the House bill.
  • A slower growth rate for Medicaid spending – this would not allow Medicaid to keep up with medical inflation, forcing further cuts in services or participation.
  • The continued provision of cost-sharing subsidies to insurers to cover costs of low-income Americans participating in the ACA insurance exchanges at least through 2019.
  • The provision of tax credits based on both income and age, as opposed to the House bill which bases tax credits solely on age.
  • States could not waive consumer protections for people with pre-existing health conditions.
  • No abortion restrictions on the tax credits used in the insurance exchanges.

The Senate's ACA replacement bill was crafted by a  handful of Republican Senators with no input from Democrats and little input from Republicans outside of the small group. The Senate Republican Majority Leader, Mitch McConnell (R-KY), has advised that there is no intention to hold any committee hearings on the bill. Senate Republicans have voiced frustration that the process has been so secretive.

A cost estimate of the Senate bill from the nonpartisan Congressional Budget Office (CBO) is expected to be released today or tomorrow. The CBO score will also indicate how the Senate bill will impact healthcare coverage for Americans. Senate Majority Leader Mitch McConnell (R-KY) aims to hold a vote on the legislation later this week. Senate Majority Whip John Cornyn (R-TX) said procedural votes could be held Wednesday. Many Republican Senators have said that voting on the bill this week will not provide enough time for consideration and debate.

Because they are using a process called budget reconciliation, Republicans only need a simple majority to pass their bill. That means if all Democrats vote against the bill—a likely scenario—the bill could still pass as long as no more than two Republicans vote against it. Sen. McConnell is working this week to garner the support of Republicans who have voiced concerns about or opposition to the discussion draft of BCRA that was released last week.

So far, 10 Republican Senators have indicated that they oppose or have concerns with the bill. These include: Senator Ted Cruz (R-TX); Senator Dean Heller (R-NV); Senator Ron Johnson (R-WI); Senator Mike Lee (R-UT); Senator Rand Paul (R-KY); Senator Shelley Moore Capito (R-WV); Senator Bill Cassidy (R-LA); Senator Susan Collins (R-ME); Senator Lisa Murkowski (R-AK); and Senator Rob Portman (R-OH).

Senator Heller said last Friday that he opposes the current version of the bill, and it will be “very difficult to get me to yes” because the proposal “takes insurance away from “tens of millions of Americans and hundreds of thousands of Nevadans."

Two moderate Republicans, Senators Collins and Murkowski, oppose the provision that would bar any federal reimbursements next year to Planned Parenthood. “I have very serious concerns about the bill,” Sen. Collins said, adding that a score from the Congressional Budget Office "will be so important" in helping her decide on her ultimate position. Senator Collins also said last week that she “want[s] states to have more flexibility, but…think[s] coverage for mental illness and substance abuse for example, and maternity care are essential."

Democrats immediately condemned the draft upon its release last Thursday. Senate Minority Leader Chuck Schumer (D-NY) noted that the president had asked for a bill with more "heart" than the House bill, but this bill is "every bit as bad" as the House version and may be "meaner." "This bill will result in higher costs, less care and millions of Americans will lose their health insurance, particularly through Medicaid," Sen. Schumer said. Senator Ron Wyden (D-OR), advised Thursday, “After all the talk about throwing out the House bill and starting fresh, the Senate proposal still slashes Medicaid to fund big tax breaks for the wealthy, raises costs and guts protections for people with pre-existing conditions.”

Governors Sandoval of Nevada (R), Kasich of Ohio (R), Walker of Alaska (I), Hickenlooper of Colorado (D), and Edwards of Louisiana (D) have voiced concerns about the bill to their Senate counterparts. In fact, a group of seven bipartisan governors sent Majority Leader McConnell a letter on June 16, 2017 asking for bipartisan solutions and the protection of Medicaid. An excerpt from the letter states: “Unfortunately, H.R. 1628 [the American Health Care Act], as passed by the House, does not meet these challenges. It calls into question coverage for the vulnerable and fails to provide the necessary resources to ensure that no one is left out, while shifting significant costs to the states. Medicaid provisions included in this bill are particularly problematic. Instead, we recommend Congress address factors we can all agree need fixing.”

The fate of the ACA replacement legislation remains highly uncertain.

FY 2018 Budget and Appropriations Update

House Republicans are hoping to pass a budget resolution this week with reconciliation instructions for tax changes that are needed to avoid a filibuster by Senate Democrats. The budget resolution will be an important piece of the Republicans’ strategy for overhauling and cutting taxes and will provide a blueprint for deep cuts to domestic programs.

The House Appropriations Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and Related Agencies—which sets funding for WIC—plans to mark up its FY 2018 spending bill this Wednesday at 10am in 2362-A Rayburn House Office Building. The markup will be live-streamed here