- After a nail-biting procedural vote on Tuesday afternoon that required Vice President Mike Pence to break the tie, the Senate continued its tumultuous afternoon by voting down the Better Care Reconciliation Act, which included deep cuts to Medicaid and the option for payers to sell health insurance plans that do not meet the Affordable Care Act's Essential Health Benefits (EHB) requirements.
The BCRA was defeated 43-57 as nine GOP Senators, including Susan Collins (ME), Bob Corker (TN), Lindsey Graham (SC), Dean Heller (NV), Tom Cotton (AR), Mike Lee (UT), Jerry Moran (KS), Lisa Murkowski (AK), and Rand Paul (KY), declined to move the bill ahead.
Under Senate rules, the legislation needed 60 votes to pass.
The naysayers had previously expressed doubts about the bill and its potential impact on their state constituents, although all but Senators Collins and Murkowski voted in favor of the initial motion to proceed to debate on Tuesday afternoon.
The BCRA’s demise is just the start of a packed week of legislative action that GOP leaders hope will end with at least some major changes to the Affordable Care Act. The party’s strategy is complicated by the fact that lawmakers are still not entirely sure what they will ultimately be voting on.
While a full repeal of the law is extremely unlikely – and extremely unpopular, according to public opinion polls, with more than 61 percent frowning on the possibility – the Republican leadership is hopeful that they will be able to dismiss some of the ACA’s most controversial provisions when all is said and done.
A “skinny repeal” is still on the table, which would overturn tax penalties for failing to meet the individual insurance mandate and would no longer require employers to offer health insurance to their full-time employees. The proposal would not end Medicaid expansion in states that have chosen to pursue the safety net program.
While the narrowly-focused plan may seem more palatable to GOP Senators concerned about steep premium increases and coverage losses due to the austere Medicaid cuts included in the BCRA, a December 2016 Congressional Budget Office (CBO) estimate of what would happen with a repeal of the individual mandate may also be worrisome for patients and payers.
Fewer healthy patients are likely to purchase insurance if not required to do so, the CBO says, skewing risk pools towards sicker, higher-cost individuals and forcing payers to raise premiums to compensate for more expensive care.
About 15 million more patients are expected to be uninsured by 2026 without the individual mandate, the CBO estimated. While many of those patients are likely to voluntarily refuse coverage, the move is anticipated to result in higher premiums for those who require more extensive aid from their insurance programs.
In the coming days, the Senate will move into voting on a slew of amendments proposed by both Democrats and Republicans, many of which are likely to be more symbolic than anything else. Whether or not GOP leaders will be able to get any major changes past skeptics across the conservative ideological spectrum remains to be seen, however.