The U.S. Senate failed to pass a bill to replace the Affordable Care Act before starting its holiday recess last week. On June 27, as the proposal fell short of the necessary support, Senate Majority Leader Mitch McConnell (R-Kentucky) postponed the vote, but opponents caution that the bill is not yet dead.
The bill, known as the Better Care Reconciliation Act, would slash federal Medicaid spending and leave 22 million more people without health coverage over the next decade, according to the Congressional Budget Office.
Advocates say the bill would hurt people with disabilities, seniors in nursing homes, and people living with HIV and other chronic health conditions. At the same time, wealthy individuals and the health insurance industry would see a tax cut.
"The Senate health care bill will be catastrophic for our nation's health care system," said AIDS United president Jesse Milan. "If passed, not only will people living with or at risk of HIV and sexually transmitted diseases suffer, but our efforts to end the HIV and STD epidemics will be impeded."
Repealing and replacing the ACA, popularly known as Obamacare, has long been a top Republican priority. The House narrowly passed its version of the legislation, known as the American Health Care Act, on May 4. At the time Senate Republicans said they would not approve the same bill, but changes have been �" and are still being �" made to address the demands of reluctant lawmakers, ranging from less severe Medicaid cuts to more funding for the opioid epidemic to those who want more cuts made to the bill.
The BCRA would reduce federal Medicaid spending by $772 billion, with the phase-out starting in 2020. By 2026, an estimated 49 million people under the Senate bill and 51 million under the House bill would be without health coverage, compared to 28 million if the ACA remains in effect, according to the CBO.
Nearly two-thirds of states have taken advantage of Medicaid expansion, and more than 40 percent of people living with HIV rely on Medicaid, according to the Kaiser Family Foundation. The bill would stop Medicaid funds from going to Planned Parenthood, which is a major provider of low-cost reproductive health care, HIV testing, and PrEP in many communities.
"The Senate bill closely mirrors the House bill, which has been widely criticized as 'mean' and the worst bill for women's health in a generation," said Planned Parenthood President Cecile Richards. "Each and every senator should listen to the American people and vote against this legislation."
President Donald Trump himself referred to the House bill as "mean." Last Friday he suggested in a tweet that he was open to repealing Obamacare now and trying to come up with a replacement later.
Like the House bill, the Senate proposal would revoke the mandate that individuals must carry health insurance or pay a penalty. The BCRA would cut federal tax credits to buy insurance and raise the income threshold to be eligible for a subsidy. While some healthy young people could see lower monthly premiums, costs would likely skyrocket for many middle-aged and older individuals.
Senate Democrats are unanimously opposed to the BCRA. The proposal will require all but two Republican senators to vote in favor, but several have expressed hesitation �" some because they think the proposal is too harsh, and others because it does not go far enough.
Republican senators who have expressed opposition include Susan Collins (Maine), Dean Heller (Nevada), Ted Cruz (Texas), and Rand Paul (Kentucky). Paul is among those angling for full ACA repeal.
Repeal of the ACA is expected to have a big impact in California, which could lose more than $12 billion annually in federal funding for Medi-Cal (the state's Medicaid program). San Francisco Health Director Barbara Garcia, a lesbian, previously told the Bay Area Reporter that the ACA has extended health coverage to approximately 133,000 people in San Francisco, including 93,000 covered by Medi-Cal expansion.
Advocates express concern
Local and national patient advocacy and health care provider organizations expressed opposition to the BCRA.
"Like the version of this legislation approved by the House of Representatives, the Senate bill is a punishing and draconian proposal that prioritizes tax cuts for the rich over health care for the poor and sick," said Project Inform Executive Director Dana Van Gorder, a gay man.
"The Senate [bill] will result in the loss of health care for millions of Americans and make efforts to end the HIV and hepatitis C epidemics much more difficult," he added. "Many other Americans, especially seniors, will pay more for their health care coverage while receiving less actual coverage."
Loss of health care coverage is expected to have a particularly detrimental effect on people living with and at risk for HIV.
"The Medicaid program, and more recently the Medicaid expansion, have been pivotal to progress against the HIV epidemic in the U.S. because consistent access to care and treatment for people with HIV allows them to stay healthy, have near normal life expectancies, and prevents transmission of the virus," said Dr. Wendy Armstrong, chair of the HIV Medicine Association.
Advocates lauded the BCRA vote postponement, saying it reflects widespread pressure on lawmakers. But the bill is not yet dead, as debate will resume when the Senate goes back into session July 10.
"As a country, we must build upon, rather than abandon, the recent progress we have made to increase access to health care coverage, thus improving the health of Americans and importantly, beginning to turn the tide of America's HIV epidemic," Armstrong continued. "We appeal to our senators to reject the BCRA and send a signal that health care for all Americans is a priority."