Publisher's Synopsis
Per the reconciliation instructions in the budget resolution for FY2017, the House passed its reconciliation bill, H.R. 1628-the American Health Care Act (AHCA)-with amendments on May 4, 2017. The House bill was received in the Senate on June 7, 2017, and the next day the Senate majority leader had it placed on the calendar, making it available for floor consideration. The Senate Budget Committee published on its website a "discussion draft" titled "The Better Care Reconciliation Act of 2017" (BCRA) on June 22 and subsequently updated the discussion draft on June 26. The Senate's draft legislation is written in the form of an amendment in the nature of a substitute, meaning that it is intended to be considered by the Senate as an amendment to H.R. 1628, as passed by the House, but that all of the House-passed language would be stricken and the language of the BCRA would be inserted in its place. Both the AHCA and the BCRA would repeal or modify provisions of the Patient Protection and Affordable Care Act. For example, both would substitute the ACA's premium tax credit for premium tax credits with different eligibility rules and calculation requirements, and both would effectively eliminate the ACA's individual and employer mandates. Both the AHCA and the BCRA also would make a number of changes to the Medicaid program. They would repeal some parts of the ACA related to Medicaid, such as the changes the ACA made to presumptive eligibility and the state option to provide Medicaid coverage to non-elderly individuals with income above 133% of the federal poverty level (FPL). They also would amend the enhanced matching rates for the ACA Medicaid expansion and the ACA Medicaid disproportionate share hospital (DSH) allotment reductions. In addition, both the AHCA and the BCRA include new programs and requirements that are not related to the ACA. For example, under each, a new fund would be created to provide funding to states for specified activities intended to improve access to health insurance and health care in the state. The most significant Medicaid-related new provisions in the AHCA and the BCRA would convert Medicaid financing to a per capita cap model (i.e., per enrollee limits on federal payments to states) starting in FY2020 with a block grant option for states. Both also include a provision that would permit states to require nondisabled, non-elderly, non-pregnant adults to satisfy a work requirement to receive Medicaid coverage. The AHCA and the BCRA both contain provisions that could restrict federal funding for the Planned Parenthood Federation of America (PPFA) and its affiliated clinics for a period of one year, and each would appropriate an additional $422 million for FY2017 to the Community Health Center Fund. Both would repeal all funding for the ACA-established Prevention and Public Health Fund (PPHF), and both would repeal many of the new taxes and fees established under the ACA. Although the AHCA and the BCRA share many provisions, the BCRA strikes some AHCA provisions and adds some new provisions. For example, the BCRA does not include the AHCA's provision that would repeal the requirement for private health insurance plans to meet a generosity level based on actuarial value. Furthermore, the BCRA would not allow states to apply for waivers from three federal requirements that apply to private health insurance issuers; instead, the BCRA would modify the current law state innovation waivers. In other examples, the BCRA strikes a Medicaid provision in the AHCA that would let states disenroll high-dollar lottery winners, and the BCRA adds a few new Medicaid provisions, including provisions providing states the option to cover certain inpatient psychiatric services for non-elderly adults and to establish Medicaid and State Children's Health Insurance Program (CHIP) quality performance bonus payments.
