Senate Releases Draft ACA Repeal and Replace Bill

On June 22, the Senate released its version of legislation that would repeal and replace significant portions of the Affordable Care Act (“ACA”). The 142-page discussion draft, titled the Better Care Reconciliation Act (“BCRA”), is the first legislative text released by Senate leadership to repeal the ACA, and it is distinctly different from the American Health Care Act that was passed by the House earlier this year.

BCRA would allow states to choose, starting in 2020, between receiving Medicaid in a block grant from the federal government or through a per capita cap system based on the number and type of enrollees. The payments would increase each year, but, starting in 2025, the growth rate would be lower than what the House bill prescribes. For the 31 states that have expanded Medicaid, the Senate bill would allow them to receive enhanced federal payments for three years. Starting in 2021, enhanced federal payments would then be rolled back over three years to traditional Medicaid funding rates.

Similar to the House bill, the Senate draft would keep the ACA requirement on pre-existing conditions and allow children to stay on their parents’ insurance until age 26, but it would eliminate the ACA’s individual and employer mandate. The bill would keep in place the ACA’s premium subsidies for two years. Eligibility would then be scaled back slightly to 350 percent of the federal poverty level and extended to more low-income people who don’t qualify for Medicaid. The Senate bill also drops the House’s so-called MacArthur Amendment for an approach that lets states do more with waivers already available under the ACA and that makes those waivers easier to obtain. BCRA would make existing 1332 waivers easier to obtain and allow states greater leeway.

The Congressional Budget Office (“CBO”) announced its intention to release its analysis of the cost of BCRA early next week. The estimate will contain projected coverage losses and deficit savings arising from policy changes in the bill. Senate Republican leadership is pushing to vote on the bill as early as next Thursday, ahead of Congress’s July 4 recess. Since Senate Democrats remain unified in their opposition, Republicans can only lose two members and still reach the required 50-vote threshold, with Vice-President Pence breaking the tie.

CMS Releases 2018 MACRA Proposed Rule

On June 20, CMS published the massive 2018 MACRA rule. The 1,058-page proposed regulation carries out the 2015 law that seeks to overhaul the payment of doctors based on quality measures. CMS’s stated goal behind the regulation is to simplify the program, especially for small, independent and rural practices, while ensuring fiscal sustainability and high-quality care within Medicare.

The proposed rule would amend some existing requirements and also contains new policies for doctors and clinicians participating in the Quality Payment Program that would encourage participation in either Advanced Alternative Payment Models or the Merit-Based Incentive Payment System (“MIPS”). CMS had already exempted from MIPS those doctors who bill Medicare no more than $30,000 a year or those who see fewer than 100 Medicare beneficiaries. According to the CMS proposal, the threshold will be increased to $90,000 in Medicare charges or 200 Medicare beneficiaries.

Doctors in small practices also could seek exemptions from electronic health record (“EHR”) requirements. Additionally, CMS proposed delaying a requirement to upgrade EHRs for practices of all sizes. The rule also calls for encouraging providers to upgrade to 2015 certified EHR technology by offering bonus points on performance scores of those that made the switch. A CMS fact sheet provides a digestible 23-page summary of the regulation.

Health-Related Bills Introduced This Week

Sens. Roger Wicker (R-MS) and Brian Schatz (D-HI) reintroduced legislation that would allow non-rural health providers that serve predominately rural areas to become eligible for the FCCs rural broadband support fund. Currently, the FCC program is only available to providers in rural areas.

Rep. Sam Graves (R-MO) introduced a bill (H.R. 2957) that would amend Titles XVIII and XIX of the Social Security Act to provide enhanced payments to rural health care providers under the Medicare and Medicaid program.

Reps. Michael Burgess (R-TX) and Diana DeGette (D-CO) introduced the Preventative Health Savings Act of 2017. The bill is intended to allow the CBO to recognize savings realized beyond the traditional 10-year budget window. Some members have long believed that legislation dealing with health service delivery changes to chronic care has not been recognized by CBO for the long-term savings.

Next Week in Washington

The House and Senate return on Monday for a full legislative week. Majority Leader Mitch McConnell (R-KY) has been adamant the Senate will vote on BCRA before Congress breaks for the July 4 recess. Four of the more conservative members of the Senate have already announced their opposition to the current form of BCRA. Thus, the Republican leadership will need to modify the bill to appease at least two of these members without losing the support of more moderate members.