Last week, the Senate released the Better Care Reconciliation Act (BCRA) to repeal and replace the Affordable Care Act (ACA). Below is NCOA’s analysis of how the proposal would affect our nation’s seniors.
What’s in the bill?
The BCRA is similar to the House-passed American Health Care Act (AHCA). But it also includes new elements that could further impact people on Medicaid and those with chronic conditions. Here are some highlights:
Medicaid is a lifeline for 7 million vulnerable older adults who depend on it, primarily for long-term services and supports that are not covered by Medicare. BCRA would:
- Cut Medicaid by $772 billion by 2026, according to the Congressional Budget Office.
- Fundamentally change how Medicaid is funded by capping the federal contribution based on a preset formula that would grow at a fixed rate, below the actual cost of care. Medicaid cuts under the BCRA would rise rapidly after 2026 because of a much lower growth rate starting in 2025. Experts predict that implementing caps will result in states significantly reducing Medicaid services.
- Repeal the Community First Choice program, which gives states incentives to provide seniors and people with disabilities access to home and community-based services. This change mirrors the House bill.
- End the ACA Medicaid expansion beginning in 2021, one year later than the AHCA.
Just like the House bill, BCRA weakens the Medicare Trust Fund by repealing the ACA tax provision that imposes a 0.9% payroll tax on incomes above $200,000 for single individuals and $250,000 for couples. This means that the Trust Fund would be insolvent 2 years sooner—in 2026 instead of 2028.
Prevention and Public Health
The BCRA eliminates the Prevention and Public Health Fund created under the ACA. For older adults, the Fund includes funding for Chronic Disease Self-Management Education (CDSME) and Falls Prevention. But it also has improved access to disease prevention, vaccines, and health screenings for all Americans. The House bill would eliminate the Fund in October 2018, but the Senate proposal would eliminate it one year earlier in October 2017.
Under the ACA, insurers cannot charge pre-Medicare older adults with non-group coverage premiums that are more than three times what they charge younger adults. Under both the House and Senate bills, insurers would be able to charge these seniors five times or more for premiums.
In the BCRA the premium subsidy is income-based, and tied to the cost of the lowest tier of coverage in the exchange. This is different than the House bill, which gives low- and middle-income people a set tax credit based on age. In both bills the subsidy is less than in the ACA.
The House and Senate bills both allow states to apply for a waiver that would let them define the essential benefits covered in their state. This would allow insurance plans to deny coverage for benefits that they previously were required to cover.
The AHCA cuts taxes by $663 billion over 10 years, primarily for wealthy Americans and corporations, largely paid for by cuts to Medicaid. According to the Urban Institute and Tax Policy Center, millionaires would gain about $40 billion in tax cuts every year once the bill’s provisions are fully in place. A preliminary analysis appears to indicate that the Senate BCRA bill would include similar tax cuts between $550-600 billion.
The Senate is expected to vote on its ACA repeal and replace bill this week. With a 52-48 margin, Republicans can afford to lose only two votes to pass the bill. The vote will be very close.
If the bill passes the Senate, the House is expected to take up and likely pass it sometime before July 4.
NCOA will continue to oppose provisions that would harm older Americans and urge that Congress pursue a bipartisan bill that improves coverage and quality, while reducing out-of-pocket costs.