​The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) on March 13 released a score, or assessment, of the American Health Care Act, the House Republican Affordable Care Act (ACA) “repeal and replacement” bill making its way through Congress.

CBO said several major provisions of the Republican proposal would result in a decrease of $880 billion in direct federal Medicaid spending and 14 million fewer enrollees from current levels to the year 2026. And next year, in 2018 alone, 5 million fewer people would be covered by Medicaid, CBO and JCT said.

The loss of the nearly $1 trillion in direct spending would culminate “in 14 million fewer Medicaid enrollees by 2026, a reduction of about 17 percent relative to the number under current law. Some of that decline would be among people who are currently eligible for Medicaid benefits, and some would be among people who CBO projects would be made eligible as a result of state actions in the future under current law (that is, from additional states adopting the optional expansion of eligibility authorized by the ACA),” CBO and JCT said.

Congressional Republicans and the Trump administration want to end the open-ended funding system Medicaid has always operated under and replace it with a per-capita cap on federal spending, allocating to the states funds that they can disperse to enrollees as they see fit.

CBO and JCT said “some decline in spending and enrollment would begin immediately, but most of the changes would begin in 2020, when the legislation would terminate the enhanced federal matching rate for new enrollees under the ACA’s expansion of Medicaid and would place a per capita-based cap on the federal government’s payments to states.”

The long-awaited CBO/JCT numbers stand in contrast to the administration’s statements on how the Republican bill would impact coverage for not only Medicaid, but also for non-group market enrollees. Last week on March 10, Health and Human Services (HHS) Secretary Tom Price said on MSNBC that the ACA replacement bill would not result in anyone losing coverage. “We don’t believe that individuals will lose coverage at all, so long as they’re able to select the kind of plan that they want for themselves and for their family,” Price told the network.

Even before CBO and JCT released their report, health care experts said the long term care community’s worry about the Medicaid program and the loss of federal funds under a per-capita cap were warranted. “The highest level of analysis says this is going to significantly reduce the federal contribution to Medicaid,” Howard Gleckman, senior fellow, Urban Institute, tells Provider.  

“Medicaid either provides benefits to fewer people or states decide to reduce benefits,” he adds. “There is no way around it. A per-capita cap mostly means less money to provider services for each beneficiary.”

Gleckman also says there will likely be a “Shark Tank” effect on states and Medicaid funding, with representatives from the various “buckets” of people who currently are served by the program fighting one another for funds from the per-capita caps. “Per-capita caps are probably better than the pure block grant alternative, where there would be one pot of money available for everybody,” but even under the Republican cap idea the “resources for LTC will still decline.”

And criticism also came from within HHS on the Medicaid plans of the Republican legislation. Andrey Ostrovsky, MD, chief medical officer of the Center for Medicaid and CHIP Services, on March 8 tweeted a blunt rejection of the proposal. His message said, “despite political messaging from others” at HHS, he sided with provider and physician groups in opposing the Republican bill’s impact on the Medicaid program.

The next steps for the Republican health care proposal is for the House Budget Committee to combine the different parts of the bill on March 15. The House Energy and Commerce and Ways and Means committees approved two different parts of the repeal and replace legislation on March 9, and now it has to be unified before being sent to the House Rules Committee and possibly the House floor for a vote during the week of March 20. The Senate, under House Speaker Paul Ryan’s (R-Wis.) schedule, would take up the bill the week of March 27.

But, some Senate Republicans continue to speak out against not only the Ryan timetable but also the content of the legislation, with one of the most vocal being Sen. Tom Cotton (Ark.). On March 13, Cotton said on a conservative talk show that the discussion by Ryan and the Trump administration of a three-phased approach to repealing and replacing the ACA is just “politicians’ talk,” and is not achievable in the Senate.

Price last week said the American Health Care Act was just the first of three phases, with the second being regulatory changes by the administration and the third being additional legislation, like to allow the sale of health insurance across states lines. But, Cotton pointed out to the radio show that while the repeal and reform bill only needs 50 votes to pass the Senate under “reconciliation” rules, the additional legislation would need 60, which may not happen with Republicans only holding a 52-48 majority.

In a possible White House move to shore up support for “repeal and replace” in the Senate, Sen. James Lankford (R-Okla.) on March 13 told The Hill newspaper that he and other conservatives in the Senate Republican Steering Committee have talks scheduled at the White House. Conservatives in both the House and Senate object to the current language in the repeal and replace bill, calling it “Obamacare Lite,” in reference to refundable tax credits and other measures that either mimic or maintain ACA provisions. Meanwhile, Democrats have not wavered from their dislike of any Republican effort to gut the ACA.

The machinations of the conservative bloc in Congress has mystified some analysts, who don’t understand its strategy. “There seems to be a fundamental misunderstanding among Republican conservatives—both members of Congress and outside groups—on how Republicans can ‘repeal’ and ‘replace’ the ACA,” said Chris Condeluci, principal of CC Law and Policy, and former Republican Senate Finance Committee staffer who worked on ACA negotiations in 2009 and 2010.

“In short, a ‘reconciliation’ bill can only impact 1.) spending and 2.) taxes. Which means, you cannot ‘repeal’ and ‘replace’ all of the ACA’s insurance market reforms through the ‘reconciliation’ process,” he said. “But, for some reason, Republican conservatives don’t want to accept the reality of the conditions that come with passing legislation through the ‘reconciliation’ process.” 

Instead, Condeluci says, they want to engage in a public display of civil disobedience in hopes that Senate leadership takes extreme measures, like eliminating the 60-vote threshold rule, or firing the parliamentarian, or encouraging Vice President Pence to overrule the parliamentarian to allow full repeal of all of the insurance market reforms on the Senate floor.