Dr. Oran Smith

The Better Care Reconciliation Act: Seven Conservative Concerns

July 17, 2017

Dr. Oran Smith

UPDATE: 7/19/17

If you’ve been following the healthcare debate in Washington, we wouldn’t be surprised if you have whiplash by now. First, the stated goal is “repeal and replace,” then it becomes “repeal!” Now, it’s “we’re making progress on repeal and replace again.”

Thus, while Republicans are searching for a viable path forward, PPI is glad to provide clarity on what to watch for in the debate. For example, no matter what, Medicaid is a huge part of the healthcare equation. Here’s how Former Senator Jim DeMint frames that issue:

“Medicaid is a ‘last resort’ health insurance option for patients, doctors and states.  Research shows that the health status of people on Medicaid is no better than people with no insurance at all.  Politicians who claim to help people by forcing them onto Medicaid are only helping themselves.  The priority of the federal and state governments should be to empower citizens to buy personal insurance plans that they can afford and keep.  States can accomplish this goal if the federal government block grants Medicaid money back to the states and lets them regulate their own insurance markets.”

Though the political winds are shifting constantly, another way to mark the progress of applying free-market solutions to America’s healthcare policy conundrum is to critically examine the most recent Senate bill. This can guide us in what to watch out for as the debate rages on:


Here is a list of seven conservative concerns about the July 13 Senate version of the “repeal-and-replacement” of Obamacare known as The Better Care Reconciliation Act. A special thanks to the brilliant analyst Chris Jacobs of The Juniper Group for his assistance in compiling this list.

  1. Amends the short-term Stability Fund, by requiring the Centers for Medicare and Medicaid Services to reserve one percent of fund monies “for providing and distributing funds to health insurance issuers in states where the cost of insurance premiums are at least 75 percent higher than the national average.” Is this essentially an earmark for Alaska? It is the only state that would qualify.
  1. Includes language allowing late-expanding Medicaid states to choose a shorter period (but not fewer than four) quarters as their “base period” for determining per capita Wait a minute. Does this incent states (that unlike South Carolina) decided to expand Medicaid to the able-bodied?
  1. Increases opioid funding to a total of $45 billion—$44.748 billion from Fiscal Years 2018 through 2026 for treatment of substance use or mental health disorders, and $252 million from Fiscal Years 2018 through 2022 for opioid addiction research—all of which are subject to few spending restrictions. So, who controls this spending? Looks like the federal HHS will have a lot of money and a lot of power over the spending of it.
  1. Grants the Secretary of Health and Human Services the authority to exempt other individuals from the continuous coverage requirement. Again, like Obamacare, that is a lot of authority for the Secretary of HHS.
  1. Does NOT allow non-compliant plans to waive or eliminate requirements related to annual and lifetime limits, or coverage for “dependents” under age 26. This is a missed opportunity for real choice as the more competitively priced plans with fewer Obamacare type coverage requirements would be over-regulated. That’s not conducive to real consumer choice.
  1. Does NOT allow non-compliant plans to waive or eliminate requirements related to a single risk pool. Same issue. Tying the hands of “non-compliant” (non-Obamacarish) plans reduces freedom.
  1. Uses $70 billion in Stability Fund dollars to subsidize high-risk individuals in states that choose the “consumer freedom” option. This provision could be nothing more than a frightfully expensive “hold harmless” or a pure bailout of the insurance industry.

There are many good provisions in the Senate bill. This list merely encapsulates some of the concerns expressed by conservatives. Stay tuned!

Commentary is Dr. Oran Smith’s