‘‘Better Care Reconciliation Act of 2017’’

BREAKING NEWS: The Senate version of the ACA Repeal Bill was released today. It's a draft and the final bill will most likely change before it's put up for a vote. Here's what the 142-page discussion draft says and what's next:

The Senate bill kept most of the House version principles, including:

• Individual and employer mandates go away. No mention of the continuous coverage requirement in the Senate version. (This will drive up rates if there is no mandate or requirement to get and keep coverage.)
• Cuts nearly $1 trillion in Medicaid funding over a decade,
• If Medicaid expansion is repealed, the cuts would be more gradual under the Senate version (Senate version won't touch until 2021 - House plan freezes in 2020)
• Permits states to relax the rules for essential health benefits (what services or conditions health plans must cover),
• While the House version based subsidies on age, the Senate bill ties subsidies to income - which may be too similar to the ACA for hardline GOP senators.
• Senate bill allows states to implement work requirements for Medicaid enrollees who are "able to work".
• Repeals the Cadillac, HIT and medical device taxes; Cuts taxes for wealthiest 1%,
• Provides lower subsidies for the middle-class,
• Strips all federal funding for Planned Parenthood (could be a problem for some Republican senators like Collins, Murkowski who support leaving funding in place),
• Senate version alters the ACA's 1332 waiver policy by removing the requirement to cover as many people and be as affordable.
• Would extend the ACA cost-sharing subsidies for two years. (Trump threatened to cut off payments which insurers say could destabilize the individual market.)
• Pre-existing conditions are still "protected" but BCRA allows states to waive what is required to be covered which weakens this protection.

Still, the Senate bill does not address costs of health care, the underlying costs which drive higher premiums. Calling the bill a "Better Care" will invite heavy criticism that as many as 24 million Americans may lose coverage and quality of coverage could be compromised if states eliminate essential health benefits to help mitigate rising costs.

WHAT'S NEXT:

As of 11:30AM EST, Speaker Paul Ryan "has not yet read the bill" but was briefed on the draft. He and Senate Majority Leader McConnell urge senators to read the bill.

• Will face heavy criticism from both sides for being written in secret, with no public hearings and several Republican complaints of not being allowed to provide input or participate in the process.
• The work group: Only 13 GOP male senators from ten states (eight of which from states that did not expand Medicaid).
• Minority Leader Sen. Chuck Schumer: "The Senate bill is a wolf in sheep's clothing" and even meaner than the House version with deeper cuts and more lost coverage.
• Senate GOP leaders say it will be debated for 20 hours, then senators will vote on an unlimited amount of amendments to make changes.
• A CBO score is expected by Monday, June 27.
• Senate Majority Leader Mitch McConnell says a vote could happen before the July 4th break - as early as next Thursday.
• Senate requires 50 votes to pass the bill, with VP Pence breaking a tie. All 46 Democrats expected to oppose; Republicans have a challenging task to somehow appeal to both moderate and hardline conservatives. (Mission impossible?)
• Republicans can afford to lose only two GOP senators; using a special budget process called reconciliation that allows them to bypass a Democrat filibuster.
• If it's passed, the Senate must reconcile their bill with the House version to form one "repeal and replace" bill the president can sign into law.

It seems unlikely a bill will be put to a vote before the July 4th break. There's just not enough time to reconcile the many unanswered issues or the devasting impact to Medicaid expansion states and other key points GOP moderates and conservatives don't agree. Here's what some experts think about the secretive draft process, the steep challenges, the pending CBO score and why conservatives are irritated and won't or can't support the bill.

(UPDATE 6/24)

The Fifth GOP Senator to Oppose The Health Care Bill: Sen. Dean Heller (R-NV): "This bill that’s currently in front of the United States Senate ... is simply not the answer, and I’m announcing today that in this form I will not support it," Heller said at a news conference in Las Vegas with Republican Gov. Brian Sandoval Friday morning, pointing to the bill's dramatic reductions in Medicaid.

Medicaid Protectors: Sen. Heller is the only Republican senator up for re-election in 2018 in a state won by Clinton (also a Medicaid expansion state). But Heller is not alone. The ACA is pretty popular in Arkansas, Kentucky, and Louisiana; red states that expanded Medicaid coverage through the ACA. Medicaid cuts will hurt these states.

The Conservatives: Sens. Rand Paul (R-KY), Mike Lee (R-UT), Ted Cruz (R-TX) and Ron Johnson (R-WI), released a joint statement saying they weren’t ready to vote for the bill as-is, but “we are open to negotiation and obtaining more information before it is brought to the floor.”. (Why opposed? It just doesn't repeal Obamacare enough.)

The Opioid States: Sen. Rob Portman (R-OH), and Shelley Moore Capito (R-WV), are concerned the GOP bill undermines efforts to curb the opioid epidemic in their states.

Planned Parenthood: Sens. Susan Collins (R-ME), and Lisa Murkowski (R-AK), defended the women's health organization and said it shouldn't lose funding. (Hyde Amendment already prohibits federal funds from being used for abortions.)

With only two GOP votes to spare, the needed votes seem less likely unless negotiations are made and closed-door politics magically arrive at some compromise. I don't see it.