A bad process leaves the Senate with nothing but bad options


The Congressional Budget Office (CBO) this week scored several versions of the misguided health care legislation put forward by Senate Republicans, finding that between 22 and 32 million Americans would lose coverage if any of these bills were passed into law. Public opposition from moderate senators including Susan Collins (R-ME), Shelly Moore Capito (R-WV), and Lisa Murkowski (R-AK) has forced Majority Leader Mitch McConnell (R-KY) to consider several possible paths forward, all of which will prove challenging.


  • The Better Care Reconciliation Act (BCRA) was introduced in mid-June and would take away coverage for an estimated 22 million Americans. Its failure to garner support from a majority of Senate Republicans is why other bills are now in play.
  • An updated version of the BCRA included an amendment from Sen. Ted Cruz (R-TX) that would deregulate the insurance market and allow providers to offer plans for those with pre-existing conditions that would be separate from (and likely much more expensive than) plans offered to those without. The CBO has not scored this bill, in part because it, too, lacks the necessary support to move forward.
  • Yet another updated version of the BCRA that does not include the Cruz amendment received its CBO score earlier today, and would also result in 22 million losing coverage.
  • The Obamacare Repeal Reconciliation Act (ORRA) was introduced yesterday, and would repeal the ACA without a replacement – commonly known as “repeal and delay.” Instead, Congress would be given two years to come up with an alternative plan. Over the next decade, CBO estimates that ORRA would cause 32 million Americans to lose coverage.

As McConnell continues trying to find a way forward, uncertainty over which version of repeal will be put to a vote next week – and whether it would include a replacement for the Affordable Care Act (ACA) or not – is a fitting conclusion to a process that has lacked transparency and failed to incorporate the expertise of healthcare providers, including America’s 3.6 million nurses.

The American Nurses Association continues to oppose these efforts because they all fail to meet our principles for health system transformation.

Each of the bills under consideration would:

  • Lead to unaffordable premiums for seniors and individuals with pre-existing conditions.
  • Cut or cap Medicaid and end state-based Medicaid expansion, which would have a devastating impact on those who can’t afford health care in the private market.
  • Worsen the opioid and suicide epidemics, at a time when states are struggling to cope with the toll these epidemics have taken.

Nurses have joined with concerned citizens across the country to make their voices heard, and are closer than ever to defeating these bills. It’s critical that we send a clear message to our representatives: reforming America’s health care system should be done in a transparent and bipartisan manner, and include input from those who care for and treat patients every day.

Senate Republicans, however, are continuing to negotiate, which is why concerned advocates should continue calling their Senators and urging them to follow a process that allows adequate time for public input and embraces common-sense fixes to the ACA. Making health care better isn’t impossible, as long as nurses are given a seat at the table.

Healthcare: Take 2 in the Senate


So what’s the new plan? Prior to the 4th of July recess, Leader McConnell delayed the vote on the Better Care and Reconciliation Act (BCRA), which would get rid of the “individual mandate” implemented by the Affordable Care Act (ACA) and cap funding for Medicaid, among other major provisions. The bill includes tax credits that help people pay for coverage which are tied to income, instead of just age. It also removes taxes on high-income Americans that help pay for the ACA. However, it keeps the “stay on your parents’ plan until you’re 26 years old” rule and the rule that says insurance companies can’t charge people more if they have pre-existing conditions. A lot of people didn’t like version 1, so today, Leader McConnell revealed BCRA 2.0 in an attempt to reach 50–the magic number of votes it would take to pass this legislation through the Senate. This new language includes an unpopular amendment from Sen. Ted Cruz (R-TX), an original opponent of version 1.

BCRA 2.0 (via the Senate Committee on the Budget):

  • Out of Pocket: An additional $70 billion is dedicated to driving state-based reforms, which could include help with driving down premiums through cost-sharing, Health Savings Accounts (HSA), and other innovative ideas to help pay for health care costs. This is in addition to the $112 billion in funding already in the original bill.
  • Heath Savings Accounts for Premiums: A provision has been included in the bill that would allow people to use their HSAs to pay for their premiums.
  • Resources for Combating Opioid Epidemic: $45 billion is dedicated for substance abuse treatment and recovery.
  • Skeleton Plans: Individuals who enroll in catastrophic plans would be eligible for the tax credit subject to eligibility requirements. These plans are higher deductible plans that cover three primary care visits a year and have federal protections that limit an individual’s out-of-pocket costs.
  • Taxes: Does not include 3.8% net investment income tax, the additional Medicare Health Insurance (HI) Tax, or the remuneration tax on executive compensation for certain health insurance executives.
  • Medicaid Revisions: Disproportionate Share Hospital (DSH) changes the DSH calculation from per Medicaid enrollee to per uninsured.
    • Public Health Emergency Funds: Will not be counted toward the per capita caps or block grant allocations for the declared period of the emergency.
    • Expanded Block Grant Option: States will be allowed to add the expanded Medicaid-eligible population under the block grant if they opt to do so.
  • High Risk Population: Payments could be made available to specified health insurers covering high-risk individuals enrolled in the qualified health plans on the Affordable Care Act’s Individual Exchange.

What do the Democrats think? Yesterday, in anticipation of the release of BCRA 2.0 the House Democrats introduced their answer to healthcare reform.

“A group of House Democrats has produced its own healthcare reform proposal to improve upon the nation’s healthcare system shaped over the last 7 years by the Affordable Care Act (ACA). The New Democrat Coalition’s Affordable and Accessible Health Care Task Force has come up with the Solutions Over Politics plan to build upon the healthcare infrastructure put in place by the ACA. This plan would include an annual $15 billion reinsurance fund to pay for high-cost enrollees, continue the ACA’s cost-sharing reduction payments, increase outreach to boost enrollment in marketplace plans, implement a Medicare buy-in option for older Americans not yet eligible for Medicare, expand premium tax credits to help individuals pay insurance premiums, and expand the availability of catastrophic health plans to encourage younger, healthy people to buy coverage.” (via The Hill)

What does ANA think? We still don’t like it.

hc-3What happens next? The CBO will evaluate Version 2.0 and release a score on Monday. The CBO’s report will assess the impact of the new bill and predict how much it will cost or save the Federal Government. In the past, this hasn’t gone so well. The Senate is expected to vote on the bill soon (if Leader McConnell can rally the votes).

What are WE doing and what can YOU do? ANA will continue to urge the Senate to #ProtectOurCare. If you haven’t done so already, be sure to call your Senator and remind them to put patients first!

Buyer Beware: Ted Cruz Goes Pro-Choice


The concept of the Trojan horse is familiar to us all. After a 10 year siege of Troy, the invading Greeks pretended to sail away—but left behind the infamous horse with a group of elite soldiers hidden away inside of it. The Trojans pulled the horse into the city as their victory trophy, and the rest, as they say, is history.

But to understand why the Cruz amendment to the Senate healthcare bill is a Trojan horse that will wreak havoc on the individual insurance market, it’s necessary to understand a more complicated concept: adverse selection.

For health insurance markets to function normally there must be a mix of healthy and sick people that purchase any given product. Adverse selection occurs when purchasers of insurance recognize that they are healthier or sicker than the average consumer, and therefore buy either more or less health insurance.

This becomes a problem when sicker consumers all self-select into one health insurance product, and healthy consumers all self-select into another health insurance product. In that instance, an adverse selection problem has occurred, and the product purchased by the sicker consumers is destined for a turbulent ride as premiums skyrocket and only the sickest of the sick continue to pay them. This is the ominous “death spiral” we so often hear about.

Put in this context, it’s easy to see why the Cruz amendment to the healthcare bill presents an adverse selection problem. The Cruz amendment, as you know, will allow insurers to sell non-compliant health insurance plans alongside compliant plans. These skimpier non-compliant plans will cover fewer maladies, have higher deductibles and copays, will be exempt from requirements to provide preventative care at no out of pocket cost, and will undoubtedly be much cheaper than compliant health insurance plans.

Those who are not yet sick will flock to these plans. And the sick will stick to those that actually provide coverage. But without the benefit of a healthy mix of consumers in the compliant plans, they will be in for a turbulent ride.

If you’re healthy, this may seem like a great deal. The only change you’ll notice at first will be an increase in the number of go-fund me pages you see on Facebook for those who purchased non-compliant plans and made the mistake of getting sick, having a heart attack, or coming down with cancer. But sooner or later, we all make the change from healthy to sick, from subsidizer to subsidized—that’s life, and that’s health insurance. And when we do, we’ll all be a lot better off if we don’t fall for the Trojan horse of the Cruz amendment to the healthcare bill.