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FEDERAL | Uncertainty in the Senate Over which ACA Repeal Bill to Move Forward

Political divides among Senate Republicans have made it uneasy for leadership to determine a winning strategy to repeal and replace the Affordable Care Act. Last week, the Senate tested two approaches in an effort to confirm the 50 Republican votes needed to secure passage of a bill.

Senate Republicans initially thought the Better Care Reconciliation Act of 2017 (BRCA), introduced on June 22, would be a successful vehicle for reform. Following hesitation from party members, this bill received its first set of revisions on July 13 without ever being heard in committee or on the Senate floor. The July 13 revisions included the Cruz amendment, which would allow insurers to offer narrower plans in an effort to decrease cost. The bill also incorporated provisions intended to sway moderate Republicans, including $70 billion in new funding over seven years to help reduce costs for individuals in the exchange. Several ACA taxes on high earners were also maintained, in addition to $45 billion in new spending to combat the opioid epidemic.

Various amendments were introduced thereafter, including a proposal by Sen. Bill Cassidy, MD (R-LA) and Lindsey Graham (R-SC). The Cassidy-Graham amendment would repeal the individual and employer mandates, but transform federal funding for Obamacare – $500 billion over 10 years – into block grants to the states. Insurance regulations on preexisting conditions would be maintained, and taxes created by the ACA, with the exception of the medical device tax, would also remain in place. This amendment has not been added to the BCRA by leadership at this time.

As of July 18, Senate leadership did not have the votes to pass the BCRA. Sens. Rand Paul, MD (R-KY) and Susan Collins (R-ME) have remained firmly opposed to the legislation for weeks. Sen. Lisa Murkowski (R-AK) voiced serious concerns over the aggressive approach at entitlement reform. The final nail in the coffin came when Sens. Mike Lee (R-UT) and Jerry Moran (R-KS) jointly announced that they would oppose the legislation.

In an effort to further appease their colleagues, Senate Republican leadership offered a second set of revisions to the bill on July 20. These revisions included minor changes that attracted little attention, which is mostly due to the unchanging Congressional Budget Office (CBO) score. According to the CBO, the bill would leave 22 million more Americans uninsured over the next ten years.

Leadership has also reintroduced the 2015 repeal-only bill that the Republican-led House and Senate sent to President Obama's desk, only to be vetoed by the former President. This Obamacare Repeal Reconciliation Act (ORRA) would phase out the exchanges, subsides, taxes and Medicaid expansion over two years. According to the CBO, this will would reduce federal deficits by $473 billion between 2017-2026 and increase the number of uninsured by 32 million by 2026, relative to current law. This bill is also expected to increase the average premium on the non-group market by 25 percent in 2018. Premiums would continue to rise and almost double by 2026.

Senate Majority Whip John Corynyn (R-TX) has confirmed that the Senate will vote on Tuesday to start debate on health care reform. The real question is whether leadership will move the repeal-only bill or the repeal and replace measure. Sen. McConnell has been tight lipped about which approach he intends to pursue next week, which is likely due to ambiguous support from Senate Republicans for both measures. The Majority Leader will need 50 out of 52 Republican Senators to support the bill, which has become increasingly difficult to secure following the announcement that Sen. John McCain (R-AZ) will not immediately return to Washington due to his recent brain cancer diagnosis.

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