June 27, 2017DOI: 10.1056/NEJMe1708506
The Better Care Reconciliation Act (BCRA), as the U.S. Senate calls the health care bill released by a small working group of Republican senators last week, is not designed to lead to better care for Americans. Like the House bill that was passed in early May, the American Health Care Act (AHCA), it would actually do the opposite: reduce the number of people with health insurance by about 22 million, raise insurance costs for millions more, and give states the option to allow insurers to omit coverage for many critical health care services so that patients with costly illnesses, preexisting or otherwise, would be substantially underinsured and saddled with choking out-of-pocket payments — all with predictably devastating effects on the health and lives of Americans. What would get “better” under the BCRA is the tax bill faced by wealthy individuals, which would be reduced by hundreds of billions of dollars over the next decade — about $5,000 per year for families making over $200,000 per year and $50,000 or more for those making over $1 million, according to analysis of the AHCA, which included a similar set of tax provisions.1 We believe that that trade-off is not one to which we — physicians, patients, or American society — should be reconciled.
Under the BCRA, states could easily receive waivers to drop many of the insurance regulations created by the Affordable Care Act (ACA). Although the ACA requirement that insurers take all comers would nominally remain intact, states could reject the ACA’s mandated essential benefits, allowing insurers to refuse to cover such critical services as emergency care, mental health care, maternity care, chemotherapy, and prescription drugs, among others. In some states, health plans could become largely worthless, particularly for patients with preexisting conditions (a group that includes 23 to 51 percent of nonelderly Americans, depending on the criteria used2). By redefining essential health benefits, states would also restore insurers’ ability to place annual and lifetime limits on enrollees’ coverage, since the ACA protections against such limits apply only to benefits designated as essential.3 Older Americans all over the country could be charged five times as much as younger ones for coverage, whereas the ACA limited age-based variation to a 3:1 ratio. And the BCRA would repeal cost-sharing reductions for low-income persons as of the end of 2019, leaving them with unaffordable deductibles and coinsurance after that. As Americans know all too well from the pre-ACA era, many underinsured and uninsured people would risk being bankrupted by health care costs3 — or would die for lack of access to needed care.
Perhaps in a nod to pleas for a reform less “mean” than the AHCA, the Senate bill would phase down federal funding for the ACA’s Medicaid expansion more slowly than House Republicans proposed to do — but it would impose the same cuts in the long run, and it would implement an even more draconian version of the House’s proposal to cap federal Medicaid funding per enrollee or turn the program into block grants. All told, the bill would cut more than $700 billion from the program over the next decade. The poorest Americans, those requiring nursing home care, and those with disabilities or mental illness would suffer. These attacks on Medicaid would undercut health care for the 74 million Americans who rely on it.
Women’s health care would also suffer major blows under the BCRA. In states that chose to stop mandating coverage of maternity care, women of child-bearing age could be forced to pay unaffordably high rates for basic pregnancy coverage. Planned Parenthood would be defunded for a year, severely restricting access not just to family planning services but to an array of important preventive care services, including cancer screenings, for millions of low-income women. Another provision would prohibit the use of tax credits for any individual insurance plan that covered abortion services (with exceptions for rape, incest, and risk to the woman’s life).
And at a time when about 60,000 Americans are dying each year from opioid overdoses, the Senate bill would drastically reduce the funds available for confronting this massive crisis and providing affected people the help they need to become functioning, contributing members of society. In addition to removing many people with opioid use disorder from the Medicaid or individual-insurance rolls, the BCRA would provide a mere $2 billion over 10 years for efforts that experts estimate would cost $183 billion.4
The public response to the very similar House bill indicates that the GOP’s approach to health care reform is deeply unpopular throughout the country, with an approval rating below 20%5 — and for good reason. Like many U.S. physician and hospital organizations that are speaking out against the BCRA, we whole-heartedly oppose sacrificing Americans’ health care and health to further enrichment of the wealthy. The future of our health care system and the lives of our patients are at stake.