Senate Republican leadership released its update to the Better Care Reconciliation Act, but the jury is still out on whether this version will be able to garner the support of 50 Republicans in the upper chamber of Congress.

The update , released July 13, includes a number of provisions to sweeten the pot for conservatives, but it does little to address the concerns of the moderates in the party, particularly of those who are worried about cuts to the Medicaid program.

Among the updates is more funding for states to help encourage more local reforms. The update adds $70 billion to the original $112 billion to help fund innovative ideas to cover the cost of health care, including premium assistance, health savings account support, and other innovations. In addition, the law will allow the use of health savings accounts to pay for insurance premiums.

The GOP leadership also is putting an additional $45 billion into the fight against opioid addiction. Plus, the revised bill includes a provision to allow tax credits to be used to purchase plans that offer only catastrophic coverage.

What the new revision doesn’t do is alter the cuts in the Medicaid program, leaving unchanged the plan to phase out the expansion of Medicaid in 2021 and complete it by 2024; allowing state governors to choose between block grants and per capita allotments to help pay for their Medicaid populations; and allowing states to institute a work requirement for nonpregnant, nondisabled, and nonelderly individuals eligible to receive Medicaid coverage.

Despite the changes, the bill still faces an uphill climb.

Sen. Rand Paul (R-Ky.), Sen. Susan Collins (R-Maine), and Sen. Rob Portman (R-Ohio) have publicly stated that they are opposed to the bill. With only a 52-seat majority and no Democrats expected to vote in favor of the bill, Senate Majority Leader Mitch McConnell (R-Ky.) needs at least 50 votes under budget reconciliation rules to pass the bill. (Vice President Mike Pence would be the tie-breaking vote if the GOP can get to 50 votes.) There are other moderate Republican senators who have opposed previous iterations of the bill, and it remains to be seen if the current tweaks will swing their votes.

The increased funding for the opioid crisis could draw some of the opposing GOP moderates. But, as Julius Hobson , a health care lobbyist with the Washington-based firm Polsinelli, noted, there is “not enough money to deal with” the opioid crisis.

The bill also has provisions allowing insurers to offer catastrophic coverage policies with minimal coverage alongside more comprehensive policies, an effort to bring in healthy younger individuals who may not want more comprehensive coverage. But those provisions have sparked pushback from state insurance directors, America’s Health Insurance Plans, and the Blue Cross Blue Shield Association.

“I can’t see how this bill got better in terms of health care access,” added Mr. Hobson, a former lobbyist with the American Medical Association.

AMA President David Barbe, MD, said that the tweaks do not do enough.

“The revised bill does not address the key concerns of physicians and patients regarding proposed Medicaid cuts and inadequate subsidies that will result in millions of Americans losing health insurance coverage,” Dr. Barbe said in a statement.

“The additional funding to address the opioid epidemic is a positive step; however, those suffering from substance use disorder have other health care needs that are not likely to be addressed if they lose coverage through a rollback of the Medicaid expansion,” he added. “While stabilizing the individual market is an initial step, more bipartisan collaboration is needed in the months ahead to improve the delivery and financing of health care.”


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