Senate tweaks bill, but it still spells disaster for Montanans

Yesterday, Senate GOP leaders released a discussion draft making some changes to its bill to repeal and replace the Affordable Care Act.

The big picture: none of these changes alters the overall impact of this bill on Montana. It will leave tens of thousands of Montanans without insurance, increase insurance for many more Montanans, and shift billions of dollars in costs to the state that will likely lead to deep cuts to Medicaid coverage.

Leader Mitch McConnell has indicated that the Senate will take a critical vote early next week to proceed to this bill. Here is a quick recap of some of the changes proposed to the Better Care Reconciliation Act (BCRA):

The bill makes no significant changes to the devastating cuts to Medicaid. Previous analysis that Montana would face the loss of roughly $5 billion in federal Medicaid funds likely still holds true. While the bill adds some smaller changes to the Medicaid provisions, many of the minor “fixes” are temporary and are no substitute for actual health insurance coverage. By 2036, Congress will have cut more than a third of Medicaid funds, leaving states to figure out how to provide coverage to the most vulnerable Americans, like low-income children, seniors, and people with disabilities, with significantly fewer federal dollars to do so.

Funding for opioid treatment is a drop in the bucket compared to what Medicaid coverage and Medicaid expansion is doing. The bill adds $45 billion for states to provide opioid use treatment, but this pales in comparison to what Medicaid is already doing and can continue to do for substance use disorder (SUD) treatment. Medicaid is the single largest payor for SUD treatment. Eliminating Medicaid expansion will result in tens of thousands of Montanans losing coverage, many of whom are getting preventative care, mental health treatment, and SUD treatment that they have never received before. It’s like pulling a patient out of the ICU and handing them a Band-Aid. 

Added funds for home and community-based services creates a false sense of security for states that will face growing health care costs and a growing aging population. The bill provides states with additional federal matching funds for increased payments to providers for home and community-based services (HCBS) for aging Americans, but these funds are temporary and cannot be used to expand services to additional individuals. With the deep cuts in federal Medicaid funds, it’s unclear how helpful this will be if/when the state has to cut current HCBS to cover other mandatory Medicaid costs.

The change to move costs associated with public health emergencies outside of the Medicaid per capita cap is narrow and insufficient. This change would allow states to apply to ask the feds to exempt costs associated with a public health emergency from the per capita cap amount, but it is not at all certain how this would work. The feds could deny an application, and even if it is approved, the amount is capped and would not factor in other increased health care costs within Medicaid (ex., new technology or new drugs).

The “Cruz amendment” makes this bill even worse, and sicker and older Montanans won’t be able afford insurance. The bill would allow a state to offer pared-down plans, as long as the state provides one insurance plan that complies with current Affordable Care Act requirements. This has the effect of bifurcating our insured population into two: those who are older or sicker, who need comprehensive coverage, and those who are younger or healthier (at least healthy right now), who will choose less comprehensive coverage. By siphoning off younger individuals, those who are older or sicker and need good insurance will be forced into a plan that is very expensive (and in many cases, unaffordable). This will be particularly the case for middle-income families who are also losing access to tax credits under this bill.

Now is the time to make your voices heard. The Senate needs to scrap this bill, start over, and work in a bipartisan manner to make health insurance more affordable and stabilize the health insurance marketplace.

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