BCRA Blockage – The Players

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On Monday, July 17, the procedural vote to debate the BCRA, the first step in passage, was squandered. This came after two senators – Republicans Mike Lee – UT and Jerry Moran -KA – said that they would vote against the push onwards. Their disapproval of the bill followed the dissent of Rand Paul – KY and Susan Collins – ME last week.

Individuals on the hill aren’t the only ones to oppose the legislation. AHIP (America’s Health Insurance Plans), which represents a slew of notable healthcare providers , came out against the bill in a joint statement with Blue Cross Blue Shield of America. They stated that the Cruz Amendment in particular “. . . will lead to far fewer, if any, coverage options for consumers who purchase their plan in the individual market. As a result, millions of more individuals will become uninsured.”

This widespread opposition essentially nixes the prospects for BCRA bipartisan success. This means that, as McConnell previously stated, republicans may have to work across the aisle. This has been an idea preferred by many democrats who have adopted the mantra of “repair”, not repeal. Senator Minority Leader Chuck Schumer stated in response to the failure of the bill: “Rather than repeating the same failed, partisan process yet again, Republicans should start from scratch and work with Democrats on a bill that lowers premiums, provides long-term stability to the markets and improves our health care system.” The repeated call for bipartisan reform is a sound aim of Democrats, yet remains unfulfilled by the leading party. Why?

Because as it turns out, the battle for bipartisan repeal and replace is not over.

Round 2

It has been in a state of free-fall, transitioning from repeal and replace to repeal then back to repeal and replace for a few days. The first post-BCRA motion was to repeal and replace at a later date. This was proposed by McConnell, who stated that the Senate will vote on a 2015 bill that was vetoed by President Obama. The notion for repeal and replace was echoed by President Trump, who tweeted: “Republicans should just REPEAL failing Obamacare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!” The idea is, or seems to be, that as markets begin to collapse with the repeal of Obamacare, the Democrats (or, as he calls them, the “obstructionists”), will be forced to participate in replacement debate. This would allow for procedural motions to go through, eventually leading to a roll call vote.

Earlier today, McConnell experienced a mission drift. He told reporters that he expected to move forward next week with the procedural vote, indicating a revival of the bill – or an indication towards something new. It seems that Trump, McConnell, and Price have terraformed a landscape in which repeal and replacement is possible. However, the dissent from Republicans indicates otherwise.

In order to understand why the procedural vote is yet to materialize, one has to recognize the disharmonious nature of the Senate at present. To do this, one must look at those who protested and their incentives.

Susan Collins – Maine

As the Affordable Care Act endured, Maine saw a profound decrease in the number of its residence that lacked insurance. In 2013, its uninsured rate was 9%. In 2015, that fell to 5%, hitting a record  low. It was touted as a success story, seeing as rates of uninsured were substantially higher before enactment. Much of the newly insured crowd came from Rural Maine, which most from the introduction of the marketplace. Many rural counties now have over 10% of their population enrolled via healthcare.gov.

Repeal with the BCRA would be catastrophic. It would displace approximately 22 million Americans from their current coverage, as well as cut a substantial chunk of Medicaid spending: 26% by 2026, the CBO estimated.

Although Maine did not expand its Medicaid coverage, the picture painted by the BCRA still has some seriously sinister undertones. Maine is projected to have a decrease in healthcare employment of 6.2% in 2026. Because it has such a high marketplace enrollment, a source of employment that’s not often talked about, it is projected to see a greater increase in the number of jobs lost. A straight repeal, as McConnell is now discussing, would cause 95,000 of Maine’s residents to lose coverage by 2019.

Collins’ recognition of the BCRA’s malicious nature came out in a series of tweets, in which she stated: “I will vote no.” She cited the 22 million uninsured as well as access to rural areas and current Medicaid enrollment in Maine as reasons why.

Rand Paul – Kentucky

Rand Paul hails from Majority Leader McConnell’s turf, yet he remains opposed to his compatriot’s legislation. Kentucky has always acted as an interesting incubator for the ACA. Although it polls terribly low in the state, the uninsured rate post-enactment in Kentucky fell faster than in most areas in the country. Corbin – located in southwestern Kentucky –  saw the uninsured rate fall faster than any other region in the country.

When asked whether or not he would vote in favor of the motion to debate the BCRA, Paul said absolutely not. However, it’s not because he wants to keep Obamacare in effect. Paul finds that Obamacare is far too spending-heavy, and would be in favor of a clean repeal and replace under a two-year timeframe.

He explicated this first in a Breitbart Op-Ed, where he wrote: “the only workable solution left to Obamacare right now is to separately repeal and replace.” He railed against the Republican tribalism that he sees as driving the repeal and replace efforts, and was hawkish on regulations and taxes. In a recent USA Today Op-Ed, he wrote: “I will vote for less than what I want. I will compromise on how much repeal we can get, as long as it is not coupled with massive new spending and bailouts.” Paul represents one of the deficit hawks that have been talked about in recent weeks; he is someone who wants a flat repeal and eventual replacement in order to reduce the deficit.

Mike Lee – Utah

Similar to Paul, Lee believed that the repeal and replace plan lacked the muster that Republicans had been campaigning on for the past seven years. He believed that the ACA made healthcare “inaccessible”, and that repeal maintained a sense of urgency like never before. In a press release issued July 17, lee wrote: “In addition to not repealing all of the Obamacare taxes, it doesn’t go far enough in lowering premiums for middle class families; nor does it create enough free space from the most costly Obamacare regulations.” When asked whether or not he would vote for a clean repeal, he said “I will vote for any bill to repeal Obamacare.”

Although Utah did not expand Medicaid, it has approximately 418,000 covered by the program (2015 level). With the caps on Medicaid and substantial contraction of spending, Utah would find itself in harm’s way. Utah’s Medicaid coverage gap – the number of people not covered because the state did not expand Medicaid – rests at 63,000. ACA termination would close the door on coverage to these Utahans.

Finally, Utah’s high-risk pools, those that existed pre-ACA, resided at more than 200% market standard for premiums. With the Cruz amendment (which he helped to author), price and preexisting discrimination could resurface, proving harmful to the state. This has the potential to lead to premiums of the same pre-ACA caliber, prices that Utahans could simply not afford.

Jerry Moran – Kansas

In a statement posted to his Twitter feed, Moran stated that he still has the intent of repealing and replacing the Affordable Care Act. However, he felt that the BCRA failed to offer protections to those with preexisting conditions, did not address rising costs, and was “bad policy.”

Like many Republicans, he has sought to reduce the role of the federal government in decisions that he feels ought to be left to the states; this includes issues such as healthcare. This remains a common thread amongst many of the more conservative Republicans, whereas moderates tend to allow a bit for more room for spending. His statement specifically mentioned the threat posed by a single-payer system, one controlled by the federal government, and the hiked spending that would invoke. This seems to be a stab at the current healthcare climate of the left.

If passed, the Urban Institute expected that the BCRA would lead to a 29% increase in the uninsured adult population in Kansas. The increase for kids would jump from 6.1% to 10.5%. Kansas did not expand Medicaid.

Lessons Learned

What exactly does this mean, if anything? What lessons can be learned from the Senators and their dissent?

Well, the repeal and replacement of a law that’s been in motion for years is hard. Whether people want to admit it or not, the Affordable Care Act polls incredibly high. It’s currently at a 2:1 margin in comparison with the BCRA. The popularity of it, combined with its perceived success, make it an extremely difficult target for encroachment. It’s become an institution.

However difficult repeal and replace was, though, a clean repeal would be catastrophically worse and more difficult. Although, as we saw, there are many who advocate for a clean repeal, many moderate conservatives would not go for it. This is especially true in states that partook in Medicaid expansion and states with much more gubernatorial involvement, like Nevada.

The CBO estimates that 32 million would be uninsured if the ACA is repealed without a replacement. The CBO’s new score came out Thursday, July 20. For something that is as salient and necessary as healthcare, the answer to a clean repeal should be a no-brainer; no.

Although healthcare hasn’t always been framed as an issue of morality, this number – 32 million – is sure to pull at the hearts of senators across the board. If the Republican majority is able to pass something, it could prove catastrophic for not only the party and their incumbency, but for the country and its health.