On Thursday, Senate Republicans unveiled their latest proposal to replace the Affordable Care Act, including a new provision, among others, that would allow insurers to sell bare-bones plans with high deductibles.

The new Senate version also would add an additional $45 billion to the $2 billion already set aside to battle the nation's opioid addiction crisis.

This newest plan—meant to appease moderate and conservative Republicans—has made some changes from the originally proposed Senate bill made public in late June. But the revisions would do little to stop millions of Americans from losing health insurance they currently have or would be eligible for under the Obama-era ACA, experts and consumer advocates say.

The first version of the Senate's Better Care Reconciliation Act (BCRA) did not come up for a vote because of misgivings from moderates, and some conservatives. The bill was pulled so that it could be reworked.

discussion draft released today of the new proposal addresses some of those lawmakers' concerns. The new bill would:

  • Provide more money that states can use to help low-income consumers pay premiums. 
  • Shield some funding from massive Medicaid cuts that states might need for a public health emergency.
  • Retain some taxes on wealthy Americans and insurance industry executives to be used to pay for subsidies for lower-income Americans.
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Some health policy experts say the changes aren’t significant enough to reverse the projected decline in the number of Americans who have been able to obtain insurance since the ACA was fully implemented in 2014.

According to a Congressional Budget Office analysis of BCRA last month, by 2026, 22 million more Americans would be uninsured under the GOP plan than if the ACA remained in place. In total, 49 million people in the U.S. will be uninsured by 2026, compared with 28 million under the ACA, the analysis says.

A new CBO analysis of the updated legislation is expected Monday.

“There’s nothing in there that would cause a dramatic difference in the estimated number of people expected to lose health insurance coverage,” says Katherine Hempstead, a senior adviser who works on health insurance and health policy issues at the Robert Wood Johnson Foundation.

Hempstead expects more changes and additions before the Senate votes on a final bill.

But some consumer advocates don't expect changes that will significantly reduce the general impact of the Senate plan. 

"Senators have made some tweaks and adjustments to this bill, but the essential problems for consumers are still there," says Betsy Imholz, special projects director for Consumers Union, the policy and mobilization arm of Consumer Reports. "Tens of millions of people were projected to lose the health coverage they have today under the previous version of the bill, and this version is essentially the same. Many people would wind up paying more out-of-pocket for less coverage."

Senate Majority Leader Mitch McConnell, R-Ky., says he wants the Senate to vote by the end of next week.

The House already has passed its plan, which some Senate Republicans say was too draconian in its cuts to Medicaid, among other concerns. The Senate set about creating its own version that could win the support of moderates and conservatives. The two chambers would have to eventually agree on a common piece of legislation to successfully repeal and replace the ACA.

For years Republicans and conservatives said they wanted to repeal the ACA because of its individual mandate to buy insurance or pay a penalty, and because of the expense of tax subsidies and expansion of Medicaid funding.

McConnell and others say changes are necessary to reduce the price of premiums and to give states the flexibility to offer Americans more affordable healthcare options.

McConnell has said he thinks the approach in the Senate version of the bill will bridge the divide between moderate and conservative Republicans. 

What's New in GOP Plan

  • Option to buy cheaper but skimpier insurance. One of the biggest changes is an amendment from Sen. Ted Cruz, R-Texas, that would allow insurers to sell basic, stripped down health insurance plans that would cover fewer benefits than the ACA currently requires. By contrast, the ACA requires insurers to provide a comprehensive benefits package that covers 10 essential health benefits, including mental health, maternity care, and prescription drug coverage. Under current law, you can only get a tax subsidy to pay premiums if you buy a comprehensive plan. Another change: The Cruz amendment would allow premium tax credits to be used for the purchase of catastrophic plans. It would allow any consumer to purchase a catastrophic plan, which has minimal healthcare benefits, according to Timothy Jost, a health policy expert and emeritus professor at Washington and Law School of Law, who analyzed the changes to the legislation. Under the ACA currently, only individuals under the age of 30 and those who could not afford other coverage can buy these catastrophic plans.                     
  • Changes to pre-existing condition guarantees. These new skimpier plans proposed by Cruz would be high-deductible health plans that cover three primary care doctor visits per year and limit an individual’s out-of-pocket costs. Insurers would be allowed to charge sick people higher premiums or simply deny them coverage as long as they also offered a more comprehensive option. Most insurance industry experts say the change could destabilize the insurance market by unbalancing risk pools. Healthy people would tend to pick the cheaper, skimpier plan while sicker people would gravitate to the more comprehensive one. With more sick people in the pool for the better insurance, premiums would skyrocket, making insurance more unaffordable for many who need it most, they say. 
  • More money to cover out-of-pocket costs. The revised bill would add $70 billion in additional funds that states could use to help reduce premiums and reduce out-of-pocket costs such as deductibles and co-pays to make insurance more affordable. The bill already included more than $100 billion for such purposes.
  • Expanded use of HSAs. Health savings accounts allow people to put pretax money in an investment account to use to pay out-of-pocket healthcare costs. Under the new BCRA plan, for the first time people would be allowed to use health savings accounts to pay premiums,not just out of pocket costs. 
  • Help for elderly long-term-care needs. Medicaid is a key source of funding for long-term-care needs for the elderly. To ease the pain of the massive Medicaid cuts, the BCRA plans would allow states to apply for waivers from Medicaid spending limits to help expand home and community-based care for the elderly. 
  • More funds for opioid treatment. The Republican plan would add $45 billion to the $2 billion earmarked for substance abuse treatment and recovery programs. The more generous funding would still not be enough to cover what will be lost if Medicaid is slashed, addiction experts say.

Correction: An earlier version of this story said that the bare bones plans offered under the Cruz amendment would be eligible for tax subsidies. The new proposed plans are not available for tax subsidies.