The Front Burner:
Merits, flaws of Senate health bill.
The Better Care Reconciliation Act of 2017 — the Republicans’ Senate bill to replace the Affordable Care Act — is not perfect. Its Medicaid cuts, for example, may be too severe and lead to coverage losses. The bill, however, isn’t a finished product.
For example, Republicans just added a six-month waiting period to enroll for those who fail to maintain continuous coverage. The original draft had no penalty for failing to enroll — which would have invited abuse by people who wait until they get sick to apply for insurance. But the BCRA, which is the acronym for the bill, would move toward restoring a proper balance between the states and the federal government.
The ACA moved power and authority from consumers, employers and the states — which had previously regulated health insurance — to the federal government through a combination of new insurance regulations, individual and employer mandates, subsidies and Medicaid expansion. Yet the particular genius of our Constitution and federalism is the understanding that states are better judges of their citizens’ needs and circumstances than the federal government.
The BCRA would maintain much of the ACA’s structure. Unlike the House of Representative’s legislation — the American Health Care Act, which would use age-based tax credits — the Senate bill continues (with modifications) the ACA’s premium tax credits based on enrollees’ incomes. Like the ACA, the Senate proposal purports to guarantee insurance to people with pre-existing conditions. While the BHCA would end enhanced federal funding for the ACA’s Medicaid expansion, it would phase out the funding over three years beginning in 2021 instead of ending it abruptly in 2020, as the AHCA would do.
But the BCRA would transfer power and authority back to the states by liberalizing what’s known as the ACA’s “section 1332” innovation waivers. These waivers allow states to modify or eliminate central ACA provisions, including the individual and employer mandates, rules regarding what plans and essential health benefits must be offered on the exchanges and the premium tax credits and cost-sharing subsidies.
The BCRA would keep the ACA provisions that states can modify under 1332 but increase the likelihood waivers will be used. It would eliminate ACA restrictions on what waivers cannot do in the market, leaving only the requirement that they not increase the deficit. It also would streamline applications, create a $2 billion fund to incentivize states to seek waivers and allow states to use long-term state innovation and stability allotments for waiver plans.
A flexible and functional 1332 process would restore states’ traditional role in defining required insurance benefits. States could relax the ACA’s essential health benefits and other provisions to reflect what their citizens actually want and need. Less-comprehensive plans could yield more affordable premiums to encourage enrollment. Each state could experiment to determine what works best.
Critics complain states will allow insurers to stop covering cancer care, drugs, maternity services, and substance-abuse and psychiatric treatments or abolish benefit requirements altogether. But, with the current publicity surrounding health care, it is unlikely that people will allow their state governments to cease requiring services they consider important. In essence, the critics believe only the federal government can safeguard citizens from their own state governments.
The BCRA can be improved — it states that the secretary of U.S. Department of Health and Human Services “shall” approve waiver requests unless they increase the deficit. The secretary needs some discretion in reviewing waivers for the BCRA goals of “increasing access to comprehensive coverage, reducing average premiums, and increasing enrollment.”
Overall, however, the BCRA is welcome step toward reestablishing the flexibility and experimentation our Constitution encourages.
States could reflect what their citizens actually want and need.