One provision of the Senate's health care bill stands to be quite popular: the Better Care Reconciliation Act would eliminate the Affordable Care Act's individual mandate. That would be repealed immediately.
Another would likely please the Republican base: defunding Planned Parenthood for a year. Those funds would disappear right away, too.
Another would threaten health care coverage for millions of Americans: a rollback to the Medicaid expansion. That change wouldn't start until 2021.
Repealing Obamacare may be Senate Republicans' main goal, but it's also easy to see how the BCRA could benefit the GOP in coming elections. The provisions that stand to be more popular (and less harmful to many Americans) are front-loaded, occurring before the 2018 midterms. Cuts to premium subsidies and Medicaid come after that, and many of them are delayed until after the 2020 presidential election.
To better see how this bill could affect future politics, we've put together a timeline of when major BCRA changes would go into effect in relation to the dates of coming elections.
We've also explained the potential effects of the bill, as reported by the Congressional Budget Office and other health care experts, to try to game out how those effects could affect voters' choices.
(And to be clear, any number of factors influence people's voting choices, so this is by no means a prediction of election winners and losers.)
So here's what goes into effect when:
- Individual and employer mandates repealed (retroactive to Dec. 31, 2015)
- Planned Parenthood funding ends for one year
- States can much more easily waive aspects of ACA, including "essential health benefits"
- States get funding "for purposes of submitting an application for a waiver"
- Taxes on health savings accounts, prescription drug manufacturers and importers, health insurance providers, and investment income repealed
- States can impose work requirements on Medicaid recipients
- Tanning tax repealed
- Restrictions on using tax credits to buy plans that cover abortion go into effect
- Limits on flexible spending account contributions repealed
- Tax on medical devices repealed
Nov. 2018 — Midterm election
Prior to this point, the individual mandate — one of the most unpopular parts (maybe the most unpopular part) of Obamacare — will have been repealed. That could make midterm voters happy — and inclined to vote for Republicans — despite the fact that Obamacare has, in general, gained in popularity since Trump took office. According to the Congressional Budget Office, the elimination of the individual mandate would lead to 15 million more uninsured people in 2018 alone.
In addition, several Obamacare taxes will have been repealed by now, overwhelmingly benefiting the highest-income Americans. Those changes could please a crucial group of GOP supporters.
Not only that, but the bill will not have yet removed cost-sharing subsidies — payments to insurers that help lower-income customers afford coverage — and it will not have yet kicked in the (generally) less-generous premium support subsidies.
The Medicaid expansion likewise will not have yet been rolled back. That rollback will eventually affect millions — by 2026, it would mean 15 million more people would be off the Medicaid rolls than there would be under current law, according to the CBO.
In short, many of the potentially less-popular provisions of this law — provisions that would lead to higher premiums or deductibles (which could in turn lead to more people choosing not to buy coverage), as well as lower Medicaid enrollment — wouldn't go into effect for a while and could save the GOP some pain at the ballot box.
However, it could cause some hardship for some Americans — specifically, those who rely on Planned Parenthood for services. Government funds currently account for 40 percent of Planned Parenthood's revenue, with much of that coming from Medicaid (but none of that going toward abortions, except in cases of rape, incest and when the mother's life is in danger).
Cutting those funds could mean clinic closures or fewer services, as FiveThirtyEight explained in March. Around 15 percent of people in areas where there aren't other options for low-income people to get care would be affected, and the reduction in family planning services would mean the number of Medicaid births would go up by "several thousand."
Midterm turnout tends to be low, however — much lower than in presidential election years. So the bill could make a difference to the extent that it affects the views of many people who would vote anyway. But then, if people's experiences with it are particularly negative or positive, it could inspire them to turn out as well.
Of course, how this affects the election at all depends not only on what else is going on but also which party people blame or praise for any changes in the health care system.
- Continuous-coverage provision (six-month waiting period before obtaining insurance) kicks in
- Funds appropriated for "Long-Term State Stability and Innovation Program," a pot of money states can spend to support high-risk people in the individual markets, helping push premiums down and keeping markets stable
- Age-rating limits change, allowing insurers to charge older people up to five times higher premiums than younger people. (Under Obamacare, older people can only be charged three times more.)
- Sunsets ACA's minimum medical loss ratio, which makes sure insurance companies spend a certain percent of revenue from premiums on health care claims and improving quality, rather than in other areas, like profits and marketing
- Actuarial value for benchmark plans drops, meaning plans would cover a smaller share of costs
- Cost-sharing reduction payments to insurers stop
- Tax credits for premiums change, no longer available to people between 350 and 400 percent of the federal poverty level
- Medicaid per-capita growth for non-disabled capped at the rate of inflation for medical care
- Tax on employee health insurance premiums and benefits repealed
Nov. 2020 — Presidential election
By now, some pain may have kicked in for some Americans. Some who were formerly eligible for tax credits for individual market insurance premiums — that is, those between 350 and 400 percent of the federal poverty level — will no longer be eligible.
The cost-sharing reduction payments that benefit lower-income people on the exchanges will also end. That could lead to lower-income people paying premiums near where they are now, but also having much higher deductibles, the CBO reported this week. In other words, health care would be more expensive for many lower-income people in the individual markets, so many may simply choose not to purchase insurance.
And the amount the federal government spends to reimburse states for Medicaid will be dropping by then. If states want to maintain current levels of coverage, they will have to spend more and more of their own money. Otherwise, as the CBO wrote, states would cut spending in a number of ways:
"...cutting payments to health care providers and health plans, eliminating optional services, restricting eligibility for enrollment through work requirements and other changes, or (to the extent feasible) arriving at more efficient methods for delivering services."
Furthermore, some older Americans would by now paying more for their health insurance, though some younger Americans could be seeing smaller premiums.
But then, the number of people on the exchanges in the first place is small — around 6.4 million right now. If people on the exchanges are getting less care for more money, and if it affects their votes (that is, if those people vote), it may not be a huge bloc of voters. And the effects of these changes may be slow in coming.
"Those changes do start in 2020 and could be a problem for the election [for Republicans], but I think those market effects would be more gradual," said Caroline Pearson, senior vice president for policy and strategy at Avalere Health.
(But then, once again, all of this is contingent upon people pinning negatives and/or positive to Republicans.)
- Medicaid expansion starts to roll back: matching rate for the expansion population starts to decline
- "Trigger laws" start going into effect, ending Medicaid expansion altogether in some states
Nov. 2022 — Midterm election
Still more factors could affect these elections, particularly Medicaid cuts. These could be getting sharper in many states, with "churn" in the system having taken people off the rolls who now won't be able to get back on, with the expansion dialing back.
Federal Medicaid expansion funds fully rolled back
Nov. 2024 — presidential election
The federal spending on the Medicaid expansion would be gone entirely by now — states could maintain the expansion if they had enough money, but for many states, that's unlikely. As the left-leaning Center on Budget and Policy Priorities reports, some states would have to up their spending by 400 percent in 2024 to maintain the expansion.
Medicaid per capita growth now pegged to a lower inflation rate (meaning lower spending in the future)
Nov. 2026 — Midterm election
By now, Medicaid will be drastically changed from what it was before the bill, with work requirements in some states, caps on spending (meaning it won't adjust for recessions, for example), and much lower enrollment in general.
In addition, by now, premiums in the marketplaces will have shifted sharply. Older adults in particular could face some massive increases in premiums, as the CBO report showed.
With reporting from NPR's Gisele Grayson.