Who Knew Getting 50 Votes Could Be So Complicated? 

Let’s see, where to begin. The Senate vote on the revised BCRA was delayed while Senator McCain recovered from a medical procedure in Arizona this week. His vote was viewed as critical to reaching the magical 50 votes needed to pass the bill (VP Pence would cast the vote to break the tie).

But on Monday more Republican Senators came out against the bill. This quote from a Washington Post article sums up how challenged the GOP caucus is to get consensus:  “…Senator Lee announced that he’s against the bill because ‘it doesn’t go far enough,’ Sen. Susan Collins opposed the measure because it goes too far.”  

So what happens next?  Some have called for a reconciliation bill that repeals parts of the ACA without replacing it, such as the bill supported by 52 Senators under the Obama Administration. At the time, the vote was purely symbolic because a veto by Obama was a sure thing. But we are already hearing reports that a “repeal only” bill won’t have enough support in the Senate.  

So what needs to happen? One problem that has haunted the ACA is that it was passed with the votes of only one party. We were looking at a similar scenario for the BCRA, a bill with an approval rating down around 20% – hardly a groundswell of support from the American people. Going forward, it would be nice to see lawmakers follow the normal process for producing a bill, which includes hearings, input from both parties, and meetings with constituents to discuss the changes and build support in advance of a vote.   

Healthcare is an important issue – and we all need to get involved. Compared with other high-income countries, the US spends the most on healthcare and scores the lowest in terms of outcomes. Yet the ACA and the repeal-and-replace bills in the House and Senate have chiefly focused on improving access to care for those who buy individual coverage (18 million) and the uninsured (29 million) – about 13% of the US population. This has involved a balancing act of benefits and funding, with the ACA tilting toward higher cost, by disallowing pre-existing condition exclusions and lifetime benefit limits and adding substantial benefit requirements, and the latest Senate bill tilting toward lower cost, by allowing lesser benefits and more exposure for people in poorer health.

One hopes we will eventually find a reasonable balance, with bipartisan support. But even if we reach that promised land, we won’t have found a solution to the underlying problems driving the poor performance of the US healthcare system. Given the reality of the political process today, those solutions will have to come from employers – the highly motivated purchaser of healthcare for over 160 million Americans.