The Health Care Freedom Act Hits the Senate Floor

The “skinny repeal” would eliminate Obamacare’s mandates, defund Planned Parenthood, and lead to 16 million more uninsured.

Jonathan Ernst / Reuters

The Senate is hurtling towards some resolution in the weeks-long saga of Obamacare repeal, and after several failed votes and amendments, the final draft is finally in view. At around 10 p.m. Thursday evening, Majority Leader Mitch McConnell unveiled the text of the Health Care Freedom Act, the more dignified official title for the “skinny repeal.”

The legislation, which was reportedly finalized over lunch today in the Senate, broadly resembles the details that have leaked out about the secret plan over the past week. It would repeal Obamacare’s individual mandate, and would repeal the employer mandate until 2025, where presumably that mandate would come back or would have to be re-repealed by Congress.

The skinny repeal extends a repeal of the medical-device tax through 2020 and defunds the Prevention and Public Health Fund. It would also more than double the limits of contributions to health-savings to allow people with HSAs more flexibility in paying for deductibles and other out-of-pocket costs. This provision is somewhat significant, because it would decrease federal revenues and would need a score from the Congressional Budget Office going forward in the process.

Although provisions in the original Senate Obamacare replacement bill to defund Planned Parenthood and allow states the ability to waive essential health benefits for some insurance plans on the exchanges were rejected under the Senate reconciliation rules by the parliamentarian, this bill devotes much of its language to creative rewrites to get around those rejections.

To start, the Health Care Freedom Act still bans funding from a number of different federal sources to public providers that provide abortions—a direct stab at Planned Parenthood—but made those provisions more general. Originally, the Better Care Reconciliation Act’s attempts to defund Planned Parenthood targeted all entities that received over $350 million in federal and state reimbursements, which would have only ensnared Planned Parenthood, because of its size. But this bill lowers that threshold to $1 million, which would presumably be less hyper-targeted, and only extends the ban for a year.

This bill also adds over $400 million to community health centers. Although that amount is not specified in the bill as an offset to defunding Planned Parenthood, the two were linked in the formal introduction of the bill to the floor by McConnell.

The second parliamentary-skirting action comes on the issue of state waivers. The BCRA attempted to give states wide flexibility to essentially ignore certain Obamacare rules for exchange plans (those sold in state insurance marketplaces set up by the law), including its requirements that plans cover certain services. It did that through expanding Obamacare’s existing State Innovation Waivers program, which allows states to create insurance programs that modify rules about plan benefits and the exchanges. Under that program, however, Obamacare implements “guardrails” specifying that these state waiver programs would have to still provide coverage that is as comprehensive and affordable as comparable exchange plans.

The BCRA plan to give states much more flexibility essentially violated those guardrails, but the skinny repeal bill keeps them in place. But there’s a bit of a poison pill: Once states get the waiver, it appears their programs can’t be revoked under law under the eight-year waiver window, which means states would be rather free to ignore guardrail rules for almost a decade at a time.

Reportedly, these tweaks—which clearly maintain at least some of the spirit of previous attempts to defund Planned Parenthood and allow insurers to offer less comprehensive coverage—are enough to satisfy the parliamentarian and pass with a 50-vote majority.

According to a Congressional Budget Office score obtained by Senate Democratic staff, the effects of this bill are about what has been expected: 16 million more uninsured people and just under $200 billion in federal deficit savings. Although premium estimates were not part of the CBO’s score tables, it appears this law will have comparable effects to a proto-skinny-repeal scored Wednesday, and will increase premiums by around 20 percent over the next decade.

That’s the gist of what Senate Republicans will vote on, and what could very well end up on President Trump’s desk, should House Republicans not follow through on Speaker Paul Ryan’s lukewarm commitment to add more provisions in conference.

The so-called “skinny repeal” is not as skinny as expected—it repeals the mandates, and includes provisions like a restriction of Planned Parenthood and some insurance deregulations—and its effects on coverage and premiums would be significant. And soon, it could very well be the law of the land.