Bills

The 4 draft Senate bills floating around right now, explained

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The Senate now has four separate health care drafts floating around — and it’s not clear which bill may come to a vote, or even when that might happen. One senator has even suggested each bill ought to get a vote, with the order of votes decided at random (this really happened!).

With all these bills floating around, it’s worth taking a moment to step back and survey the Republicans’ options, when they entered the debate, and where they’re likely to go.

The Better Care Reconciliation Act

This is Senate Republicans’ first attempt at a repeal bill. Introduced in mid-June, this bill ends the Medicaid expansion and significantly scales back the tax credits for middle-income Americans who purchase private coverage.

What the CBO says: The BCRA would leave 22 million Americans without health coverage. It would reduce the deficit by $772 billion because of its significant cuts to health coverage programs.

What’s next: For this bill, not much. The first draft of the BCRA couldn’t get enough votes to move through the Senate. That is the reason we have so many other bills now circulating, building on the BCRA in hopes of gaining more political momentum.

The Better Care Reconciliation Act 2.0

After the BCRA failed, Senate Republicans introduced an updated version that would once again allow insurers to reject Americans with preexisting conditions. This was the Cruz amendment, and it was meant to win over conservatives who wanted to deregulate the health insurance marketplace. BCRA 2.0 also kept certain Obamacare taxes on high-income Americans and created a $45 billion fund to fight opioid addiction.

What the CBO says: We don’t know! The Cruz amendment’s language deregulating the individual market has reportedly been quite difficult for the scorekeeping agency to analyze. So we don’t have figures right now — although it is similar enough to the original BCRA to expect significant loss of coverage.

What’s next: Maybe a failed vote? BCRA 2.0 does not currently have enough support to move forward. An ever-growing list of Republican senators that includes Susan Collins, Rand Paul, Jerry Moran, and Mike Lee say they will not support starting debate on this bill. But it still remains the basis from which they’re working on building another health care bill. Just last night, there was talk about adding $200 billion in Medicaid funding into the mix, so BCRA 2.0 may be well on its path to becoming BCRA 3.0.

Better Care Reconciliation Act 2.0 minus the Cruz amendment

Here’s where things start to get very confusing. This version of the bill does have the Obamacare taxes and opioid funding from BCRA 2.0 but does not have the changes to the individual market (like the return of preexisting conditions). This version of the bill seems to exist solely to be scored by the CBO, which (as mentioned earlier) hasn’t yet been able to score the very complex Cruz amendment.

What the CBO says: This bill would cause 22 million fewer people to have health coverage, according to a report released this morning.

What happens next: Nada. This bill pretty much just exists to be scored by the CBO. This is not a bill that is expected to get a vote.

Obamacare Repeal Reconciliation Act

Finally, a bill with its own name! The ORRA was introduced on Wednesday. It repeals Obamacare without a replacement plan and is often referred to as the “repeal and delay” option.

This bill repeals Obamacare’s coverage expansion in 2020 and presumes that Republicans would come up with a replacement plan in the interim. This bill would end the Medicaid expansion as well as the tax credits to purchase coverage in the individual market.

The idea for the ORRA came about late Monday night, when it became clear the Senate did not have enough to votes to pass the BCRA. So Mitch McConnell suggested a new strategy: repeal Obamacare, delay the effects, and come up with a new bill over the next few years.

What the CBO says: The ORRA would cause 32 million Americans to lose coverage over the next decade. This number would obviously change, however, if Republicans came up with a replacement plan after passing this repeal bill.

What happens next: Maybe a vote? The ORRA seems to be in the mix of bills that could be debated on the Senate floor next week — if there is enough support among Republicans to start that debate.

The bottom line

There are plenty of health care draft bills floating around, but none have so far gotten support from enough Republican senators to move forward. This is why you see so many drafts in the mix right now. The details of each are different, but the goal is the same: find one that 50 Republican senators can agree on.

Misleading Chart of the Day


The Trump administration produced a misleading report to boost its health bill. This is a graph from page 5 of the report, and at first glance this looks like good news for the Senate effort: Premiums appear to go down both for plans that do comply with the Affordable Care Act benefits and for those that don’t.

But the chart is misleading. It compares the “enrollment-weighted” average for premiums in the current marketplaces, where the average age is 48, to the average premiums for a 40-year-old under the Republican plan.

That means the premiums displayed for the Cruz amendment plans are for younger people than those displayed for the Affordable Care Act. So of course you’d expect those to be lower. Hat tip to Loren Adler and Matt Fiedler at the Brookings Institution, who noticed this first. Read my full story on the report here.

Kliff’s Notes

With research help from Caitlin Davis

Today’s top news

Analysis and longer reads

  • “Eliminating The Medicaid Expansion May Cause More Damage Than Congress Realizes”: “Our findings are particularly noteworthy given that any future GOP proposals will likely attempt to eliminate the Medicaid expansion while ostensibly preserving the guaranteed issue provision of the ACA. This ill-advised strategy could have profound cost implications for anyone seeking coverage through the marketplaces, but particularly patients being treated with expensive specialty drugs.” —Justin Puckett and Jalpa Doshi, Health Affairs
  • “John McCain Was Diagnosed With A Glioblastoma, Among The Deadliest Of Cancers”: “Doctors use words like ‘aggressive’ and ‘highly malignant’ to describe the type of brain cancer discovered in Arizona Sen. John McCain. The cancer is a glioblastoma, the Mayo Clinic said in a statement Wednesday. It was diagnosed after doctors surgically removed a blood clot from above McCain’s left eye.” —Jon Hamilton, NPR
  • “Team Trump Used Obamacare Money to Run PR Effort Against It”: “The Trump administration has spent taxpayer money meant to encourage enrollment in the Affordable Care Act on a public relations campaign aimed at methodically strangling it. The effort, which involves a multi-pronged social media push as well as video testimonials designed at damaging public opinion of President Obama’s health care law, is far more robust and sustained than has been publicly revealed or realized.” —Sam Stein, Daily Beast

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