The latest changes to the BCRA do not appear to have swayed hospital opposition to the bill.


July 13—Amid ongoing tweaks to legislation to repeal and replace the Affordable Care Act (ACA), liberal, nonaligned, and some conservative policy wonks are split on the chance that any such bill will clear Congress this year.

As part of an ongoing effort to overhaul the ACA, Senate Republicans this week released their latest tweaks to the Better Care Reconciliation Act (BCRA), which would implement that reform. The latest effort at changing the bill aimed to garner the support of at least 50 Senate Republicans, the number needed to obtain passage.

The latest tweaks, which were released July 13, would allow new federal budget restrictions on the growth of Medicaid spending to be lifted for declared emergencies, eliminate three tax cuts included in the earlier bill, and increase funding to respond to the opioid crisis from $2 billion to $45 billion, according to published reports.

But many critics doubted the bill will pass—regardless of the latest or any future changes.  

 “I actually think ‘No’ because I have a great deal of difficulty of figuring out how what is before the Senate now is going to pass and how it is going to be acceptable in the House,” Alice Rivlin, former director of the Office of Management and Budget, said at a July 13 policy briefing.

Rivlin and others hoped that if the bill fails, Congress will enact some sort of stabilization for the ACA marketplaces, followed by “a serious effort to discuss in a bipartisan way” broad healthcare reforms.

“That’s very optimistic; it might happen,” Rivlin said.

Matt Salo, executive director of the National Association of Medicaid Directors, also said he did not believe Congress will pass the BCRA.

“Whether or not they come back up from the ashes and figure out a bipartisan approach by Oct. 1, I’m even more skeptical of that,” Salo said.

Chris Jennings, a consultant and former Obama administration healthcare policy adviser, agreed that the BCRA will not pass.

Mid-to-late September is the latest that Congress could enact a separate bill to authorize out-of-pocket subsidies—which a federal court ruled were never appropriated and therefore are illegal—for eligible enrollees in ACA marketplaces for 2018, Jennings said.

On the more optimistic side was Jim Capretta, a resident fellow at the libertarian American Enterprise Institute, who described the BCRA as “a Republican amendment to the ACA.” “The odds when you have a majority is that you will do something,” he said.

“I suppose by Oct. 1, they will get there,” Capretta said.

Timothy Jost, a professor at the Washington and Lee University School of Law and a prominent ACA supporter, said it remains “likely” that President Donald Trump will sign a healthcare bill into law this year, although he hoped it would be a bipartisan bill instead of the BCRA.

This week, an investors’ note from research firm Hedgeye concluded that there is a 54-46 chance that Republicans will enact a healthcare overhaul of some type, which was up from 50-50 last week.

Hospital Reaction

The latest changes to the BCRA did not appear to sway hospital opposition to the bill.

“Their revised Better Care Reconciliation Act leaves untouched the most destructive provisions of the original bill: those that would gut the Medicaid program and strip affordable coverage from millions of low-income working Americans and others who face financial hardships,” Bruce Siegel, MD, president and CEO, America’s Essential Hospitals, said in a written statement.

That followed comments Sunday by Rick Pollack, president and CEO of the American Hospital Association, during a C-SPAN interview.

“For us the big issue is really around the coverage losses that would result from the legislation, both in the House and Senate [bills], and that’s why we’ve been opposed to it,” Pollack said.

A shift in patient mix from Medicaid to self-pay, as envisioned by the BCRA, would hurt hospital revenue, according to an analysis this week from Crowe Horwath.

In hospitals located in expansion states, the share of Medicaid patients increased from 12.3 percent to 18.3 percent in hospitals between 2013 and 2016, while the self-pay mix decreased from 7.4 percent to 3.5 percent. Crowe Horwath data found that for the average hospital, every 2 percent shift in the payer mix from Medicaid back to self-pay results in a 1 percent reduction in overall net revenue.

Restart Needed

Pollack said the BCRA tweaks being considered don’t go far enough to address hospital concerns, and urged a “restart” of the overhaul of the ACA. Hospitals seek provisions that would ensure no drop-off in breadth of coverage from the ACA. Although a Congressional Budget Office (CBO) score for the bill with the latest changes was not yet ready, CBO projected for an earlier version of the bill that 22 million fewer people would have commercial insurance or Medicaid compared with the ACA.

Among the new provisions, Pollack was concerned about an amendment sought by Sen. Ted Cruz (R-Texas) that would allow insurers to sell plans that do not meet ACA regulations if they also sell a plan that does meet those rules. Pollack worried that the tweak would bifurcate the insurance market and split healthy and sick people into separate pools, while the resulting “skinny plans” would lead to more uncompensated care for hospitals.

But supporters of the bill downplayed hospital concerns, including that millions would drop out of Medicaid—which would happen largely due to the end of the individual mandate, according to CBO.

 For instance, Capretta noted that even though the BCRA reduces future Medicaid spending over the coming decade by nearly $800 billion, the bill would still allow $4.2 trillion to be spent on the joint state-federal program.

“That’s still a lot of money,” Capretta said. “The idea that no one is going to get care is false.”

He noted that the move to a Medicaid funding system of per capita caps is similar to the 2 percent annual growth cap that New York Gov. Andrew Cuomo, a Democrat, recently instituted for that state’s Medicaid program.

Salo said two-thirds of Medicaid directors support per capita caps “as a concept,” but the way that the BCRA structured them was “beyond the pale.”


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, July 14, 2017