Is the Better Care Reconciliation Act better?

This column, written in advance, has the task of appearing on July 4, Independence Day. Coming from Philadelphia which has quite a history of involvement with American independence, I wonder whether our Founding Fathers (and Mothers) could have conceived we would be spending this time in the year 2017 wrangling over health care. Probably not. But then life spans were shorter and we knew less about alternative medical options and treatments then we know today.

Washington has an odd habit and history of naming bills in words that do not necessarily describe content. Here, the case in point is whether the recent reincarnation of the House of Representative’s American Health Care Act into the U.S. Senate’s Better Care Reconciliation Act is an improvement. In other words is it better than the Affordable Care Act it was intended to replace. Many Americans including all or virtually all Democrats in Congress and many Republicans hope we will never need to find out.

It is possible that, by July 4 or shortly thereafter questions surrounding the BCRA will be a non-issue. Despite serious efforts by Mitch McConnell and Senate Majority leadership, the bill never saw the Senate floor and its early failure led to a meeting at the White House with Republican members of Congress. One of the problems with the proposed law I might describe as a “Goldilocks” problem. Remember Goldilocks in the children’s story? One was too hard, one was too soft. It was difficult to get to what is “just right.”

In terms of Republican attempts to replace the Affordable Care Act, to one group in Congress the proposed Act is too conservative and to another too liberal. Any concession to one group leads to further dissension in the other. It is hard to get to “just right.”

So here is the question. Would the Better Care Reconciliation Act actually be better? Checking it out against the basic things we would expect a health care law or health care insurance law to do, as to most aspects of the law it appears it would not. This seems to be affirmed by at least one poll that describes only 17% of Americans as being in support of the bill. Let’s take each point.

First, would the Better Care Reconciliation Act or some law similar to it, insure more Americans? The answer according to the independent Congressional Budget Office is no. The report, recently issued, indicated there would be 22 million more uninsured Americans by the year 2026. Many losses would come from eliminating enhanced federal funding for Medicaid ex-

pansion in the states and reducing federal support for the overall program. However, federal premium tax credits would also be reduced making the coverage unaffordable for many.

There are other considerations. Since the mandate to purchase health insurance would be removed both for individuals and for companies with more than 50 employees, many would simply not purchase insurance until they felt the need. One of the tradeoffs with the Affordable Care Act was supposed to be that, with Americans required to buy insurance (and lower income subsidies for those who could not afford it), the promises of removal of lifetime payment caps and the requirement that insurers allow those with preexisting conditions to be insured could be funded by a healthy group of consumers who would carry insurance. Without that understanding it is difficult to see how those promises could be fulfilled without extreme increases in premiums. This raises another question.

Would coverage under the BCRA be less expensive? Here the answer is “it depends.”

If the overall goal is to pay less in premiums it is possible under the BCRA and under the prior House of Representatives’ American Health Care Act, premiums would be lower for many Americans. However, the question is what would you be buying?

The ACA required a package of basic benefits. Under the BCRA States could request waivers to unbundle these benefits. The policy might not have prescription drug coverage or emergency care. For women the result could be that maternity coverage would not be covered. It is the difference in cost between buying a full meal at a restaurant and ordering ala carte for everything.

The ACA needs input, suggestions, and cooperation among parties, not this law, to make it better. Americans should let their representatives know this – all consistent with Independence Day thinking.