Tierney Sneed

Tierney Sneed is a reporter for Talking Points Memo. She previously worked for U.S. News and World Report. She grew up in Florida and attended Georgetown University.

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At first glance, it appeared the Senate Obamacare repeal legislation took a less aggressive approach than House Republicans to the waivers offered to states to opt-out of Affordable Care Act insurer mandates. In fact, some conservatives were griping about it.

But, while substantively the Senate GOP proposed waivers look narrower than the House bill’s version, procedurally they are incredibly more lax. That means states will have all kinds of space to wreak havoc on Obamacare’s consumer protections, even as Senate Republicans claim they’re protecting people with pre-existing conditions.

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Sen. Dean Heller (R-NV) announced Friday that he is opposed to the Obamacare repeal legislation unveiled by Senate GOP leadership this week in its current form and that he won’t vote to advance if it is brought up for a procedural vote early next week.

“In this form, I will not support it,” Heller said. Heller is up for reelection in 2018 and is from a Medicaid expansion state. He cited the rollback of expansion has his reason not to support it.

“This bill…is simply not the answer,” Heller said.

Heller faces perhaps the toughest reelection race next year of all the GOP senators who will be on the ballot, so it’s not entirely surprising he came out against the bill, given how deeply unpopular the House version of the repeal legislation has shown to be. However, it was notable that Heller would condemn the Senate proposal in such strong terms and not just for its Medicaid cuts.

“There isn’t anything in this bill that would lower premiums,” Heller said.

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Senate Republicans, in their recently unveiled bill to dismantle the Affordable Care Act, included cuts to Medicaid funding that are even more cynical than what the House version of the legislation imposed—on both a political and policy level.

To shore up the support of Senate conservatives, who might balk at how the Senate bill softened the phaseout of Medicaid expansion, Majority Leader Mitch McConnell (R-KY) made even more draconian cuts to the traditional Medicaid program in the long-term.

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The conservative complaint that the Affordable Care Act led to higher out-of-pocket costs has been so deeply ingrained into GOP Obamacare repeal talking points that even President Trump—he of “Nobody knew that health care could be so complicated” fame—managed to work it into his tweet storm messaging.

But like other aspects of the health care bill Republican lawmakers are currently pushing, their approach would likely make the problem they raised constantly to bash Obamacare actually worse.

The reasons are wonky but incredibly important, because consumers will likely see their deductibles and co-pays rise if the Senate health care overhaul bill, the so-called Better Care Reconciliation Act, goes into law. And the way the Senate proposal is structured, it also means that the tax credits offered under the GOP bill give consumers get significantly less bang for their buck, even as they largely follow the model of the ACA subsidies.

The key provision is the Senate bill’s proposal to change what is known as the actuarial value of the benchmark plans that the tax credits would be pegged to. Under the current law, the tax credits are formulated according to the second lowest premium rate for a “silver plan” in a given area, and silver plans are required to have a 70 percent actuarial value. That means that that the insurer will pay 70 percent of medical costs a typical consumer incurs, while leaving the consumer to pick up the tab for the rest via deductibles, co-pays or other cost-sharing mechanisms.

The Senate bill lowers this base level to 58 percent actuarial value, which is at the bottom end of what are known as “bronze plans” currently under the ACA. By the math of Kaiser Family Foundation vice president Larry Levitt, the value of the premium subsidies are therefore reduced by around 15 percent.

On the front end, this will make it look like premiums are lower under the GOP plan. But the reduction in actuarial value shifts that burden elsewhere, likely to co-pays and deductibles. Consumers on the older end of the spectrum will be hit especially hard by this change, due to other ways the Senate bill tweaks ACA limits regarding age and how the tax credits are doled out.

This tweak is coupled with a state waiver provision of the bill that will allow states to opt out of the ACA’s limits on cost-sharing.

A 2015 brief by the Urban Institute found that with plans at 60 percent actuarial value—the bottom limit at the time under the ACA—the out-of-pocket costs would shake out to be around $6,850 for single policies and $13,700 for family policies.

Under the ACA, at least those deductibles were defrayed for low-income consumers by insurer subsidies known as cost-sharing reduction payments. But under the Senate Republican plan, the cost sharing reduction payments will be repealed at the end of 2019, and it’s left up to the states to enact programs that could assist low income people with these deductibles.

There is a conservative philosophy that right-leaning health policy wonks will offer in favor of higher cost-sharing. They are argue that if consumers are exposed more directly to health care costs, they’ll be more selective about what services they receive, prompting market forces to drive down the prices.

This rationale was no where to be found when Republican lawmakers pointed to out-pocket-costs to slam Obamacare, even as they intended to push a plan that would only exacerbate that problem.

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Within a few hours of the release of the Senate legislation to dismantle the Affordable Care Act and overhaul Medicaid, four conservatives came out against the bill, putting Majority Leader Mitch McConnell (R-KY) two votes short of what he will need to pass it.

But this is not, by any means, the death knell for the bill, dubbed the Better Care Reconciliation Act, and it might not be even a major obstacle.

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Sen. Susan Collins (R-ME) gave the Senate health care bill released Thursday a mixed review, but zeroed in on its major cuts to Medicaid as a potential problem for her.

She took issue with how the Senate bill, starting in 2025, used a rate of growth for federal funding for Medicaid that is significantly slower than the typical increases of costs for the program.

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Senate Republicans coming out of closed door meetings Wednesday said that their bill to dismantle the Affordable Care Act will be unveiled at GOP Senate conference meeting Thursday morning at 9:30 a.m. They indicated that the legislation would also be available to the public Thursday morning, though it’s unclear exactly how it is being released.

Sen. John Cornyn (R-TX), the majority whip, also said a Congressional Budget Office score could come as soon as Friday, though other GOP lawmakers said it might not be ready until Monday.

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Rank-and-file Senate Republicans had one thing in common with their Democratic counterparts in the health care debate Tuesday: Most did not know exactly what is going to be in the GOP Obamacare repeal legislation expected to be unveiled Thursday and put up for a vote as soon as next week.

“Nobody really has a finalized health care bill. I don’t think anybody’s seen any kind of final text,” Sen. John Thune (R-SD), the No. 3 in Senate GOP leadership, told reporters Tuesday.

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A new interactive map reveals who would be most affected by the Republican Obamacare repeal bill, where those Americans live and what the effects would be. It also breaks down which areas stand to be hardest hit by coverage losses, both on a state and county level.

The map was released first to TPM by The Century Foundation. It assumed the Senate will follow the House version’s model. It assesses the effects all the way out to 2026, period that the Congressional Budget Office assessed in its score of the House bill, the American Health Care Act.

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