The Senate parliamentarian made it harder Tuesday for Senate Republicans to pass two additional provisions of their bill to replace the Affordable Care Act.
Last Friday, parliamentarian Elizabeth MacDonough ruled against a number of other measures in the Better Care Reconciliation Act, including two politically important anti-abortion provisions.
A measure in the Better Care Reconciliation Act to allow individual-market insurers to charge older people premiums five times higher than younger people cannot be passed under Senate budget reconciliation rules, MacDonough held Tuesday. The ACA only allows insurers to charge older customers three times as much.
MacDonough also held that the bill's provision allowing small businesses to band together across state lines to establish association health plans that are exempt from state regulation did not meet reconciliation rules.
Both provisions are seen by conservatives as important for making premiums more affordable for younger and healthier people. The association health plan provision has particularly strong backing from conservative groups.
Insurers firmly support increasing the age-rating band to 5-to-1, arguing that would enable them to better attract younger customers to offset the costs of older enrollees.
Now those two provisions could only be passed with 60 votes, which would require the support of Democrats who oppose the overall GOP legislation.
On Friday, the parliamentarian held that a number of other key provisions did not comply with reconciliation rules. Those include prohibitions on Medicaid funding for Planned Parenthood for one year and on abortion coverage under health plans purchased with premium tax credits.
Senate GOP leaders could overrule the parliamentarian's decisions on a party-line vote. But political observers say Senate Majority Leader Mitch McConnell will be reluctant to do so because that would jeopardize the future of the minority party's power to filibuster Senate legislation by denying it 60 votes. Some believe he would be more likely to overrule the parliamentarian if he is within one or two votes of passing the bill with those provisions intact.
Other provisions MacDonough said Friday could not be passed under the Senate's reconciliation rules and that would require 60 votes include:
- Eliminating the ACA's minimum essential benefits requirements for Medicaid managed-care plans starting in 2020.
- Appropriating funding for payments to insurers to pay for the ACA's cost-sharing reductions for lower-income exchange enrollees.
- Barring people with a lapse in insurance coverage from buying individual-market insurance for six months.
- Eliminating the ACA rule requiring insurers to pay out at least 80% in premium revenue for medical costs.
Two provisions that are prized by conservatives have yet to be reviewed by MacDonough. Many experts doubt they'll pass muster.
They are:
- Waivers for states to opt out of ACA requirements that all plans offer essential health benefits and charge everyone the same premiums regardless of pre-existing medical conditions.
- An amendment offered by Sen. Ted Cruz (R-Texas) that would allow insurers to offer plans that do not comply with ACA rules requiring all plans to offer essential benefits and barring plans from discriminating against people with pre-existing conditions.
Tuesday's rulings were posted on Democratic Sen. Bernie Sanders' Budget Committee website.
"One of the results of this absurd process is that many of the provisions in the latest Republican bill have been found to be in violation of Senate rules," Sanders wrote on the website. "Today, we have learned of two more violations—the 'age tax' and 'small business health plans' sections."
