What the House and Senate Health Care Bills Mean for States

July 21, 2017
House and Senate Bills, ACA Comparison Chart (Updated)
BCRA Summary of Funding Provisions 

BCRA Implementation Timeline
Blog: Latest Update on Congressional Health Reform Activity

The National Academy for State Health Policy (NASHP) today released an updated chart and accompanying fact sheets that reflect a revision to the Better Care Reconciliation Act (BCRA) eliminating the “Ted Cruz Amendment” which provided funding to create coverage alternatives for high-risk individuals and The Obamacare Repeal Reconciliation Act (ORRA), a bill that would repeal many of the major provisions of the ACA within a two-year period, but does not offer plans to replace those provisions.


June 28, 2017
Issue Brief: Barely Covered: Initial Analysis of Coverage and Affordability Impacts to Consumers under the Proposed Better Care Reconciliation Act
50 State Interactive Tool: Comparison of Estimated Annual Consumer Premiums: Low and High Cost County in State
50 State Interactive Tool: Comparison of Estimated Annual Consumer Premiums: In Single County in a State

This report provides an initial assessment of individual market coverage and affordability under the Better Care Reconciliation Act (BCRA) introduced in the U.S. Senate. This Issue Brief seeks to inform policymakers on three interrelated elements of the potential impacts of the BCRA on consumers and the individual market:

  1. What’s the coverage? Impact on consumers of moving to a benchmark bene t design based on 58 percent Actuarial Value.
  2. How affordable is coverage for those receiving financial help? Impact on consumers of changes to the subsidy structure.
  3. How affordable is coverage for those who do not receive financial help? Impacts of market changes on consumers who do not get nancial help to defray premium and/or out-of-pocket costs.

To provide early insight into these questions, the National Academy for State Health Policy (NASHP), in consultation with Covered California, compared the benefits, deductibles, and maximum out-of-pocket (MOOP) of silver plans offered in California, Ohio and Pennsylvania for 2017 to a benefit design that would meet the benchmark plan value proposed in the BCRA. These data interactives compares estimated annual consumer premiums for marketplace enrollees under the Affordable Care Act and the Better Care Reconciliation Act. Building on data from the Kaiser Family Foundation, the first interactive compares consumer premiums within each state for a relatively low cost and a relatively high cost county and the second allows users to view data for all counties in a state. Users can select and compare premiums for several ages, income levels and bronze or silver coverage. View the interactive tools here:


June 26, 2017
House and Senate Bills, ACA Comparison Chart
BCRA Summary of Funding Provisions 
BCRA Implementation Timeline

The Senate’s Better Care Reconciliation Act (BCRA) builds on the AHCA but includes some very significant differences. The bill restores a subsidy structure that takes into account age, income and geography but lowers eligibility for the credits from 400% FPL to 350% FPL, reduces the amount of subsidy available and  allows those under 100% of poverty to qualify for them. However the health plan for which subsidies will be available will provide less coverage and have higher deductibles. The bill restores cost sharing reductions to provide some relief from high out of pocket costs for those eligible for two years and then repeals them and provides funding to stabilize the individual market. The BCRA loosens the statutory guardrails to allow states far more flexibility to propose health reform alternatives and provides $2B to stimulate its use. Medicaid, as in the AHCA, converts to a per capita cap allocation but on a slower trajectory than that included in the AHCA and allows states to continue to cover the adult expansion group but at regular matching rates. The option for states to seek a block grant would be permanent but includes more requirements regarding coverage and other provisions than its counterpart proposal in the AHCA. Provisions in the bill address states’ interests by increasing collaboration between CMS and states and provides some limited coverage for adults in institutions for mental diseases(IMD).

NASHP has reviewed the BCRA, recognizing that it is a discussion draft and not a final proposal, and has added it to our chart comparing the ACA, AHCA and now BCRA. This document was updated on June 26th, 2017 to include language creating a continuous coverage requirement. NASHP will continue to track amendments to the BCRA and will provide more detailed analysis and comparison as the final language becomes clear.


May 9, 2017
AHCA, ACA Comparison Chart
AHCA Implementation Timeline
Stability Fund Snapshot
State Waivers Snapshot

On Thursday, May 4, the House of Representatives passed the American Health Care Act (AHCA), a major step in efforts to repeal and replace the Affordable Care Act (ACA). The AHCA now moves to the U.S. Senate, which has established a special committee to handle the bill. Early reports indicate that states can anticipate a long process as the Senate deliberates changes to the bill.

Before passage, the House added a series of amendments, modifying various components of the bill including:

  • A manager’s amendment asserting technical and policy “fixes” to Medicaid–including flexibility over block grants, work requirements, Medicaid expansion—faster repeal of ACA taxes, and a reduction of the tax threshold for medical expenses.
  • An amendment establishing a $15 billion fund that can be used for an “invisible high risk pool”.
  • An amendment allowing states to waive certain insurance requirements including age rating bands, essential health benefits, and the prohibition on medical underwriting.
  • An amendment establishing a $8 billion fund for states that opt to waive medical underwriting restrictions.

Although the Senate has signaled that it may develop its own bill, States must not lose sight of the significant changes included in the amended AHCA , such as losses of Medicaid funding, major changes to the parameters of Medicaid and insurance affordability programs, and establishment of flexible funding programs for states to support affordability and stability.

To aid in your tracking of the bill, we are pleased to provide several new and updated resources:

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.