No one other than Senate GOP leaders knows the details of their bill to repeal and replace the Affordable Care Act. But it's certain the bill would have a seismic impact on patients, providers and insurers if enacted.
Senate Republicans would have to rewrite their bill if the Congressional Budget Office and the Senate parliamentarian say it doesn't meet budget savings targets necessary to pass the bill with a bare majority. The CBO score is expected early next week.
So, here's what to watch for:
1) How tightly will the annual growth of federal Medicaid payments to the states be capped? Will the rate of allowed growth be lower than in the House GOP repeal bill? And how fast will the Senate bill wind down the Affordable Care Act's Medicaid expansion?
The House bill would limit the annual growth of federal Medicaid payments for most beneficiaries to the medical component of the Consumer Price Index, with a slightly higher rate for the elderly and disabled. The Senate may cap growth at the rate of general inflation, which is significantly lower.
2) How much leeway will states have to waive federal market rules set by the ACA for the individual insurance market? Will health plans on the exchanges be allowed to base premiums on enrollees' health status? Will they be able to eliminate benefits such as maternity care, substance abuse treatment and mental health treatment or else charge extra for them? Will they be allowed to place annual limits on drug costs?
3) How will premium tax credits be designed, and how large will they be?
It's expected the Senate's approach to premium tax credits will be closer to the ACA than the House bill, which would base the credits on age and not consider income premium costs in a particular market. But like the House, the Senate is expected to allow insurers to charge older people at least five times more than younger people, compared with the ACA's 3 to 1 limit.
4) How much money will the bill offer states to stabilize the individual insurance market and protect people with pre-existing medical conditions?
The House bill envisions distributing $138 billion over 10 years to the states for market stabilization and pre-existing condition protections. The money could be used for reinsurance, high-risk pools, direct assistance to consumers or insurers, or supplemental funding for maternity care or mental health and substance abuse treatment. States would have to spend some of their own money, too, starting with a 7% match and rising to 50%. But if they don't apply, a federal reinsurance program will exist as well.
5) What will the bill do to encourage healthy individuals to buy insurance in order to create a financially viable market for insurers?
The House bill would impose a 30% premium surcharge on people who sought to buy insurance after a coverage gap. That would replace the ACA's individual mandate tax penalty, which would be repealed.
6) Which ACA taxes will remain, and for how long?
Making premium tax credits larger and extending the Medicaid expansion for several more years will require more spending than envisioned by the House bill. But the Senate bill has to save the same amount of money over 10 years. So Senate Republicans will have to make larger Medicaid cuts or keep at least some of the ACA's taxes for a longer period, or both.
7) What special deals will be included to win the votes of individual GOP senators who have expressed wariness about the bill?
Will there be dedicated funding for opioid addiction treatment to win over senators from drug-ravaged states such as West Virginia and Ohio? Will there be enhanced premium tax credits for rural states such as Alaska, where medical costs and premiums are far higher than elsewhere? Will red states that did not accept Medicaid expansion dollars receive a funding boost under the bill's formula for setting the per capita spending cap?
