A Narrow Path Forward for the BCRA
Following a week of high-level negotiations among GOP senators, Republican leadership is planning a Tuesday vote on the motion to proceed to the House-passed American Health Care Act (AHCA) — the vehicle for their health care reform efforts. The process has been shrouded in confusion and uncertainty, as it still remains unclear what legislation Senate leaders ultimately hope to move forward. And while knowing what’s in the Senate bill may be, as Senate Whip John Cornyn said, a “luxury we don’t have,” it’s worth acknowledging that there’s still a narrow path towards passage.
The First Hurdle
It remains seriously doubtful as to whether Republicans have the 50 votes necessary to clear the motion to proceed. Sen. John McCain’s (R-AZ) diagnosis of brain cancer has left most beltway-watchers expecting him to miss this week’s vote. And Sen. Susan Collins (R-ME) appears emboldened in her opposition, sitting out key negations among undecided senators last week. Just one additional Republican defection would sink the bill before debate even begins, and depending on the direction GOP leaders decide to go, a group of moderates or conservatives may be likely to raise opposition.
If the motion to proceed is successful, Majority Leader Mitch McConnell (R-KY) will bring forward as the first substitute amendment either: (1) Republicans’ 2015 reconciliation bill that repeals significant portions of the Affordable Care Act (ACA), or (2) the Better Care Reconciliation Act (BCRA) — which could include the Consumer Freedom Amendment offered by Sen. Ted Cruz (R-TX). Leader McConnell spent the weekend gauging which bill has more support from the GOP conference, and details will continue to emerge as the vote approaches.
‘Repeal and Delay’ and the BCRA
GOP leadership spent much of last week hedging on Leader McConnell’s statement that the Senate will vote on an updated version of a 2015 bill that would repeal significant parts of the ACA, which provides two years to develop a replacement bill. It has since become apparent that such a vote will fail, as Sens. Collins, Shelley Moore Capito (R-WV), and Lisa Murkowski (R-AK) have all said they oppose it. Still, a vote on the bill — even if it were to fail — could help open debate on the BCRA, as Sens. Rand Paul (R-KY) and Mike Lee (R-UT) have promised to drop their opposition on the motion to proceed if a repeal-only vote is guaranteed.
Despite Leader McConnell’s statement early last week that repeal and replace “will not be successful,” the BCRA represents Republicans’ most viable path forward in passing health care reform legislation. The 49 GOP senators who met over lunch at the White House last Wednesday left the meeting encouraged, and negotiations among undecided senators continued at a Members-only meeting Wednesday night. Meanwhile, discussions continue over including an additional $200 billion to the offset Medicaid cuts in the BCRA to ameliorate the concerns of moderates, which could potentially be tied to a reported “Medicaid wrap-around” proposal that would give states flexibility to use Medicaid funding to cover the health expenses of people outside the program.
Any version of the BCRA to receive a vote this week is likely include Sen. Cruz’s Consumer Freedom Amendment, which would allow plans to sell both ACA-compliant and non-compliant plans. This is despite the release of legislative text by the Senate Budget Committee which does not include the Cruz amendment. The Congressional Budget Office (CBO) has not released a score including the Cruz amendment, and the methodology of the Trump administration’s friendly analysis of the amendment has been subject to criticism.
A Path Forward
For Republican leaders, the path forward on health care reform is decidedly narrow. A vote on “repeal and delay” appears inevitable to prevent Sens. Paul and Lee from blocking the motion to proceed. This vote would be expected to fail. Leaders would also have to assure moderates that they would subsequently vote on the BCRA as a substitute amendment while dispelling concerns about the scope of Medicaid cuts and coverage losses estimated by the CBO. Moderates have also avoided, so far, going on record regarding the Cruz amendment. It remains to be seen whether senators are satisfied with the Trump administration’s analysis. Further, Sens. Paul, Lee, and Jerry Moran (R-KS) have offered concerns of their own — albeit from a conservative perspective — on aspects of the BCRA.
The fallout early last week is indicative of the deep divisions among Senate Republicans on health care reform. While little has changed that dynamic, a renewed effort from the White House and an injection of $200 billion in additional funding could provide a needed boost to GOP leaders. Recall that a mere $8 billion in additional funding introduced by Rep. Fred Upton (R-MI) was enough to lift the House bill over the finish line. The likely absence of Sen. McCain this week and the intransigence of Sen. Collins will make threading the legislative needle a difficult — almost impossible — task for GOP leaders. But the BCRA could make one last gasp for revival before we finally write its eulogy. And if Leader McConnell writes the right prescription, it has an outside chance at survival.
Shea McCarthy is a Vice President at Thorn Run Partners where he and his team deliver sophisticated policy analysis, strategic counsel, advocacy services to leading health care stakeholders — from Fortune 500 companies to non-profit organizations. As a well-regarded analyst in health care policy, Shea is frequently cited by Politico, Inside Health Policy, and other media outlets. He has a B.A. in Economics from the University of Notre Dame.