The Better Care Reconciliation Act

What’s the issue? Although the American Health Care Act (AHCA), the Republicans’ effort to repeal and replace the Affordable Care Act (ACA), passed in the House, it was unable to pass in the Senate. Instead the Senate drafted their own healthcare bill, the Better Care Reconciliation Act (BCRA). That too failed to get enough support to pass. Last week, Senate Republicans updated the BCRA and tried to pass it quickly. However, they must wait for John McCain to recover from surgery in order to have the votes for it to pass. Since we’ve been granted some extra time to scrutinize this bill, I want to take a look at what’s in it and how it differs from the AHCA, which I discussed on a previous blog, here.

Why do I care?

Healthcare represents about one sixth of the US economy, and its rules and regulations affect us all. In this post I’m going to talk about the differences between the AHCA passed by the House and the BCRA proposed by the Senate. Check out my previous blog to learn about the differences between the ACA (what we have now) and the AHCA. Many of those differences are still present in the BCRA.

1. Tax credits: The tax credits available to individuals in the BCRA to purchase health insurance are more generous than those in the AHCA. The credits are most closely tied both to income and to the cost of insurance. These are good things. However, the CBO still estimates 22 million fewer people would have insurance in the next decade than under the ACA (a very slight improvement over the AHCA’s 23 million people). This is because the tax credits are not generous enough to account for total healthcare spending. The Brookings Institution studied total healthcare spending in 2026 for individuals under the ACA and the BCRA and found that across all ages, poorer people would pay much more under the BCRA, sometimes up to 70% of their income.  Bottom line: The BCRA’s tax credits are slightly better than the AHCA, but it is still unaffordable for the poor.
2. Essential Benefits and Pre-existing conditions: The BCRA does not directly allow insurers to deny coverage based on pre-existing conditions, but it makes other changes that would amount to the same. Most notably, the BCRA, like the AHCA drops the Essential Benefits Requirement. This means that states could offer insurance plans that do not cover all of the ACA’s “essential benefits,” which include things like prescription drug coverage, maternity coverage, and mental health coverage. So, young and health people who only need bare-bones coverage (and don’t take prescription drugs, for example) will buy the cheaper bare-bones plans. Meanwhile, people who need more extensive coverage won’t have the option to buy the bare-bones plans, so they will have to buy more comprehensive and expensive plans. Since they will be more likely to use their comprehensive plans than the young, healthy people will be likely to use their bare-bones plans, the price of the two plans will be further driven apart. In the end, people with pre-existing conditions (or who are otherwise likely to need healthcare) will pay significantly more for their insurance. Bottom line: Essential Benefits still not required, which will in effect allow for discrimination based on pre-existing conditions.
3. Medicaid: Like the AHCA, the BCRA ends the ACA’s expansion of Medicaid. Additionally, both the AHCA and the BCRA impose a per-capita cap on federal spending for Medicaid recipients. Currently, Medicaid is paid for by a mix of federal and state funds. With a cap on federal spending, which is projected to increase at a slower rate than the current expected-growth rate, it would be up to states to make up the difference in funding by raising taxes or cutting services. These combined changes are projected to result in 15 million fewer Medicaid enrollees by 2026. Today, Medicaid covers 49% of births in the United States, 76% of all poor children, 64% of all nursing home residents (many of whom began retirement as middle class and outlived their savings), and 60% of all children with disabilities. Bottom line: The BCRA, like the AHCA, makes disastrous cuts to Medicaid, which will disproportionally hurt mothers, children, the elderly, the poor, and those with disabilities.

After the original version of the BCRA did not get enough Republican support to pass, the Senate released some revisions on July 13th. These revisions do not significantly alter the structure of the bill or meaningfully affect what I’ve discussed above. The revisions do get rid of a 3.8% tax cut for Americans who make over $200,000 and allocate $45 billion for the opioid epidemic. $45 billion is more than allocated in the ACHA, but it still falls short of what is needed and does not take into account the additional harm that would be caused by fewer people having access to insurance and to Medicaid. You can read more about how the BCRA would affect the opioid epidemic on my blog here.

What can you do if you care too?

1. Call your Senators! Especially for this, especially right now, this is so important. It is widely seen that the delay in voting on the BCRA will be a problem for the bill due to increased pressure on senators to oppose it. So increase that pressure!
2. Don’t forget call your governor. Some governors have been vocal about opposing the BCRA, and can put pressure on senators who support it. Find your state governor and his or her contact information here.
3. Learn more about the changes proposed in the BCRA and who would be the most affected. You can read my take on how the BCRA would hurt maternal mortality here, or why the BCRA threatens children with disabilities and people in nursing homes. Then share the information with your friends and family.