Ohio GOP Sen. Rob Portman, for one, worries that Medicaid cuts would slash drug addiction treatment during an opioid epidemic. Nevada's Dean Heller said he can't support the current bill. If the Senate passes it, the bill goes back to the House, where its prospects are uncertain.
Most healthcare industry leaders expressed fear and anger over the bill.
"The BCRA moves in a dangerous and harmful direction for poor, aged and disabled Americans and the health plans and providers that serve them," said Margaret Murray, CEO of the Association for Community Affiliated Plans. She complained that the bill would repeal the ACA's tax penalty for not buying insurance without an alternative mechanism for prodding younger, healthier people to buy coverage. That could cause a "death spiral" in the individual insurance market, she warned. America's Health Insurance Plans and the Blue Cross and Blue Shield Association were silent last week.
The bill—which McConnell is expected to revise this week to meet concerns raised by GOP senators—would cap federal payments to the states for most beneficiaries at the medical component of the Consumer Price Index starting in 2020. Those payments would grow even more slowly after 2025.
Tax credits for people to buy individual insurance would be limited to those with incomes up to 350% of the poverty level, below the ACA's 400% cut-off. The credits would be pegged to age, income and local premiums.
The credits would be based on the price of plans covering just 58% of medical costs, compared with 70% under the ACA. The bill would end the ACA's cost-sharing subsidies for lower-income enrollees. Plans could also charge older people five times as much as younger enrollees, compared to a 3-to-1 limit under the ACA. That means consumers, particularly people ages 50 to 64, would pay much more out of pocket.
From the frontlines of the battle over healthcare reform: Get thoughts, opinions and comments made on the BCRA.
The ACA's enhanced federal payments for Medicaid expansion would be phased out from 2021 to 2023. That would likely cause 31 states that expanded Medicaid to end that coverage. Phasing out expansion funding would come on top of caps in federal Medicaid payments to the states that the CBO said would hold spending growth below actual per capita costs.
The bill also would encourage states to opt out of ACA essential benefit requirements, such as maternity care, cancer screening, mental health and addiction treatment, and prescription drugs.
"The BCRA creates a backdoor way for insurers to offer less generous coverage to fewer people and to make coverage unaffordable for patients with pre-existing conditions," said Dr. Jack Ende, president of the American College of Physicians.
Insurers celebrated the bill's provision of $112 billion for reinsurance and market stabilization measures, which would end after 10 years. They also cheered the elimination of the ACA's requirement that plans spend at least 80% of premium revenue on medical care.
Insurers especially liked that cost-sharing reduction payments to help low-income enrollees afford deductibles and copayments would continue for two years.
Ceci Connolly, CEO of the Alliance of Community Health Plans, which represents not-for-profit insurers, said that move offered some market certainty.
But Bernard Tyson, CEO of Kaiser Permanente, a member of Connolly's group, panned the Senate bill.
"We are now at risk of losing ground in building the American healthcare system we deserve," he wrote. "Racing to reform healthcare without offering a workable alternative with broad national support is not the way to go."
—Alex Kacik, Mara Lee and Shelby Livingston contributed to this article.
