It is no more. With the defections late on July 17 by two conservative Republicans, Senate Majority Leader Mitch McConnell (R-Ky.) could not muster the 50 votes required to pass the Affordable Care Act (ACA) repeal and replace legislation that was once considered a must-do for the party in control of the White House and both chambers of Congress.

For the nation’s nursing care center and assisted living owners, and their residents, the end to the Better Care Reconciliation Act (BCRA) staved off the possibility of deep and lasting cuts to federal financing for the Medicaid program, a main funding source for the elderly and disabled. 

In response to the Senate bill’s failure, American Health Care Association/National Center for Assisted Living (AHCA/NCAL) President and Chief Executive Officer Mark Parkinson said “on behalf of the nation’s long term care providers, care givers, patients and families, we look forward to a collaborative dialogue with policymakers on providing quality care that meets the needs of the most vulnerable citizens.” 

Scott Tittle, executive director, NCAL, said the industry’s stance on Medicaid was clear. “When the Congress began consideration of repealing and replacing the Affordable Care Act, our message to protect Medicaid coverage of long term care was consistent, and we are pleased that the message was heard,” he said. “We will continue to work with the administration and Congress on policies that advance quality care for home and community-based services like assisted living.” 

McConnell, with the support of President Trump, had planned to bring the latest iteration of the BCRA to a vote this week. But, the untimely illness of Sen. John McCain (R-Ariz.) forced the majority leader to delay a procedural vote until at least next week. That vote will never happen now, as the schism within the Republican caucus proved too much for the BCRA, which was also severely wounded by polling showing the public liked the ACA better than congressional repeal and replace proposals, and near universal objection by health care industry stakeholders representing providers, payers and consumers. 

But the death blow for the Senate version of the House-approved American Health Care Act (HR 1628) released on July 13 came after Sens. Mike Lee (R-Utah) and Jerry Moran (R- Kan.) said the Senate bill did not go far enough in ending the ACA. They joined with Sen. Rand Paul (R-Ky.) and Sen. Susan Collins (R-Maine) in being against the legislation; Paul from the conservative side and Collins from the moderate camp that disliked Medicaid cuts and health coverage limits. In fact, Collins said as many as 10 Republicans had concerns about the BCRA.

It was not just Washington policymakers who were troubled by the BCRA. For instance, over this past weekend, many leaders at the National Governors Association meeting in Rhode Island expressed reservations about the Medicaid cuts in the Republican proposal. At the meeting, Avalere Health delivered a report showing how the federal funding reductions would affect every state. California, for example, would lose between $37 billion and $52 billion between 2020 and 2027. 

The Avalere report mainly echoed what the Congressional Budget Office (CBO) said about the BCRA. The nonpartisan CBO’s score of the bill showed that, over the period of 2016-2027, the BCRA would cause some 22 million Americans to lose health insurance and reduce federal funding for Medicaid by $772 billion via turning to a per-capita cap or block grant funding mechanism for states. By 2036, CBO said federal Medicaid funding would be nearly 35 percent below current law. 

Sara Rosenbaum, founding chair of the Department of Health Policy, George Washington University School of Public Health and Health Services and a commissioner on the Medicaid and CHIP Payment and Access Commission, says such reductions would be “a catastrophe of epic proportions.”

Now, McConnell has vowed to hold a vote on legislation to repeal the ACA and replace it two years later. The repeal and delay plan passed both the Republican House and Senate in 2015, but was vetoed by President Obama. The previous proposal did not include structural changes to the Medicaid program, as seen in the BCRA. However, CBO had said that, if implemented, the 2015 bill would deprive some 32 million Americans of health insurance in its first year. ​

Chris Condeluci, principal, CC Law and Policy, says the repeal and delay scenario once had only a slight chance of winning approval.

“But now it appears to be happening [the up or down vote]. Query whether 50 senators will vote YES on the 2015 ACA repeal bill. To me, this sets up a classic Senator Kerry scenario: ‘Sen. X voted for it [in 2015], before they voted against it,’” he says.