UPDATED: Senate Republicans come up with one big pile of Crapo.

(sigh) Via Peter Sullivan & Stef Kight of Axios:

Scoop: Senate GOP chairs circulate health plan as clock ticks on ACA subsidies

Two key Senate Republican chairmen are circulating the outline of a health care plan to Republican offices ahead of a crucial week that could decide the fate of enhanced Affordable Care Act subsidies, multiple sources tell Axios.

Why it matters: The plan from Finance Committee chair Mike Crapo (R-Idaho) and health committee chair Bill Cassidy (R-La.) does not extend the tax credits past their expiration at year's end, instead providing funds to enrollees in health savings accounts, according to a summary obtained by Axios.

It's not the only GOP plan that's been floated in recent days as Republicans struggle to unite around health care policies.

What's inside: Certain ACA enrollees earning less than 700% of the federal poverty level would receive $1,000 in an HSA if they're 18 to 49 years old, and $1,500 if they're 50 to 64, according to the outline distributed to Senate offices over the weekend.

It would also fund ACA cost-sharing reduction payments that would lower overall premiums but cut subsidies to some ACA enrollees.

Other provisions expand the availabilty of low-cost "catastrophic" health plans and cut Medicaid funding to states that provide coverage to undocumented immigrants.

Via the actual outline...

Before I get into the proposal, even the "overview" flat-out lies about the impact of the expiring tax credits, claiming that they "only account for 4% of the premium increase in 2026" which is nonsense. This claim is based on a KFF estimate which says that:

In their 2026 filings to state regulators describing their requested premium increases, ACA Marketplace insurers said they would charge about 4 percentage points more, on average, than they otherwise would have because they expected healthier people to drop Marketplace coverage if enhanced premiums tax credit expire.

Let me say this one more time: Four percentage points is not the same thing as 4 percent. If premiums are increasing by 26% on average, 4 percentage points is actually 15.4% of the increase.

But that's just a quibble; the percent vs. percentage point thing is a pet peeve of mine.

OK, with that, let's look at the actual provisions of the bill:

• It would give $1,000 in HSA funding to "eligible" enrollees aged 18 - 49 or $1,500 to "eligible" enrollees aged 50 - 64 if their household incomes are under 700% FPL, IF they enroll in a Bronze or Catastrophic plan only, with a prohibition on those funds being used to pay for abortion or gender transition services.

Setting aside the 700% FPL cut-off & the abortion/gender transition bit for a moment, this is still insanity as it doesn't take household income into account in any way.

First, let's look at someone who might actually benefit from this, at least a little: Consider a single 30-yr old earning $30,000/yr here in Oakland County, Michigan.

In 2025, if they choose a Silver plan they're also eligible for robust CSR assistance. This means they can get a Silver HMO for as littles as $44/month with a maximum out of pocket (MOOP) ceiling (which includes the deductible, co-pays, coinsurance etc) of $1,900.

They could also get a Bronze plan for as little as $0/month, but it would include a MOOP ranging from $7,200 - $9,200.

In 2026, without the enhanced tax credits, the Silver plan will triple to at least $152/month while the MOOP will jump to at least $2,200.

The Bronze plans start at $13/month...but with a MOOP ranging from $7,500 - $10,600.

Tossing $1,000 at them (but only if they enroll in Bronze or Catastrophic) would knock the MOOP down to...$6,500 - $9,600.

So a Silver plan would still cost them a minimum of $1,300 more next year, and even a Bronze plan would still cost them at least $156 more in premiums while possibly saving them up to $700 net in out of pocket costs...maybe.

But that's an absolute best-case scenario. It's far more likely that they would break even at best, and could still face much higher total costs at worse. And this is one of the more favorable examples.

Now let's look at a 60-yr old earning, say, $65,000/yr...again, here in Oakland County, Michigan.

In 2025, they can get a Silver plan for $448/month with a $6,500 MOOP, a Bronze plan for $315/mo with a $9,200 MOOP, or a Gold plan for $437/mo with an $8,100 MOOP.

In 2026, Silver plans start out at $1,068/month ($7,650 MOOP); Bronze plans start at $733/mo ($10,600 MOOP), and Gold starts out at $1,153/mo ($8,200 MOOP).

That means right now they're looking at paying at least $7,440 more for Silver, $5,016 more for Bronze or $8,592 more for Gold.

That $1,500 HSA won't reduce any of those a dime. In fact, it'll only make the MOOP $100 less than it is this year, and that's only if they choose the Bronze plan, and only if they actually come close to maxing out their out of pocket costs.

So they'd still be spending $5,000 more to possibly save $100.

And keep in mind that MICHIGAN WILL HAVE THE 11th LOWEST UNSUBSIDIZED PREMIUMS IN THE COUNTRY NEXT YEAR.

Let's try the same 60-yr old, but this time they live in, say, Nashville, Tennessee.

In 2025, they can get a Silver plan for $457/month with a $8,900 MOOP, a Bronze plan for $199/mo with a $9,200 MOOP, or a Gold plan for $443/mo with an $7,800 MOOP.

In 2026, Silver plans start out at $1,597/month ($8,900 MOOP); Bronze plans start at $1,159/mo ($10,600 MOOP), and Gold starts out at $1,530/mo ($8,200 MOOP).

That means right now they're looking at paying at least $13,680 more for Silver, $11,520 more for Bronze or $13,044 more for Gold.

The $1,500 HSA would, again, possibly save them $100. Maybe.

Believe me, you don't want to see the examples from, say, Connecticut, Alaska, Wyoming or West Virginia.

But wait, there's more!

• It would formally appropriate CSR reimbursement payments to insurance carriers starting in 2027.

Doing this would slightly reduce gross premiums for enrollees over 400% FPL (currently around 1.6 million middle/higher income enrollees) but would also eliminate Silver Loading, which in turn would significantly INCREASE net premiums for nearly all enrollees earning 200 - 400% FPL who choose Bronze, Gold or Platinum plans (currently around 5.7 million moderate-income enrollees).

Yes, that's right: In most states, it would make the very Bronze plans that they're trying to push people into enrolling in...more expensive.

• It would make anyone eligible for Catastrophic plans (which have massive deductibles & out of pocket cost ceilings) regardless of age or income.

This would pretty much defeat the point of having Catastrophic plans in a separate risk pool, since the only real benefit Catastrophic plans have over Bronze plans is that they're generally a bit cheaper, and the only reason they're cheaper is because they're restricted to enrollees under 30. Older enrollees would still be subject to the 3:1 age band which means a 64-yr old would still be paying 3x as much for a Catastrophic plan as a 21-yr old...which would often cost more than a Bronze plan.

As I noted in my initial write-up about Trump opening the floodgates on Catastrophic plans via regulatory changes earlier this year, it's not necessarily a terrible idea, just a fairly pointless & useless one.

For instance, in the case of the examples I listed above:

• In Oakland County, Michigan, the least-expensive Catastrophic plan still costs more than the least-expensive Bronze plan.
• In Nashville, Tennessee, it doesn't matter, because there aren't any Catastrophic plans available next year anyway.

Note that the memo doesn't clarify whether the remaining federal tax credits could be used to pay for Catastrophic plans (which they can't be now) or whether Catastrophic plans would be rolled into the main "Metal Level" risk pool, although considering it refers to them as "Copper Plans" I suspect both of these would be the case...but who knows?

OK, what else?

• It would penalize states which choose to provide healthcare coverage to undocumented immigrants using their own funds (so much for federalism/states rights).

• It would further "require states to verify citizenship or eligible immigration status prior to coverage under Medicaid." This is something which is already required (I believe if a "Medicaid" program is fully funded by the state it's not technically "Medicaid" even if it's identical in every other way in terms of services, providers, etc.) In other words, this just means more paperwork for no clear purpose.

• It would prohibit federal Medicaid funding for gender transition services and would formally exclude gender transition services from being considered an Essential Health Benefit for exchange policies (the latter was already done by the Trump Admin via regulatory changes earlier this year as well).

Basically, this is a big piece of shit which should be laughed off the Senate floor if it ever reaches it.

UPDATE: They've published the legislative text of the bill.

In addition to everything laid out above...

• Unlike traditional Health Savings Accounts, you wouldn't be able to roll the money over from one year to the next.

• It allows the HSA money to be used for abortions in cases of rape, incest, or "in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed."

• The CSR reimbursement funding provision wouldn't apply to plans which provide coverage of abortion (other than in cases of rape/incest/life of the mother).

Now that would be an interesting twist...because, as I noted last summer when Senate Republicans originally considered including this provision, a bunch of blue states require insurance policies to cover abortion, which means that in this scenario, Silver Loading would be ended in red states but not in some blue states.

Which in turn means that over 18x as many ACA enrollees living in red states would be harmed by this provision than those living in blue states.

• As I speculated about earlier, sure enough, the bill would roll Catastrophic plans into the same risk pool as the rest of the metal levels:

"RISK POOLS.—Section 1312(c)(1) of the Patient Protection and Affordable Care Act (42 U.S.C. 18032(c)(1)) is amended by inserting ‘‘and including enrollees in catastrophic plans described in section 1302(e)’’ after ‘‘Exchange’’.

• The next section (201) appears to eliminate the 90% FMAP (Federal Medical Assistance Percentage) for ACA Medicaid expansion enrollees in states which provide any type of healthcare coverage to undocumented immigrants (Edwin Park says it wouldn't completely eliminate the increased FMAP but would knock it from 90% to 80%, which would still be untenable for many expansion states):

"...provides any form of financial assistance from a State general fund during such quarter, in whole or in part, whether or not made under a State plan (or waiver of such plan) under this title or under another program established by the State, to or on behalf of an alien who is not a qualified alien and is not a child or pregnant woman who is lawfully residing in the United States and eligible for medical assistance pursuant to section 1903(v)(4) or for child health assistance or pregnancy-related assistance pursuant to section 2107(e)(1)(Q), for the purchasing of health insurance coverage (as defined in section 2791(b)(1) of the Public Health Service Act) for an alien who is not a qualified alien and is not such a child or pregnant woman; or provides any form of comprehensive health benefits coverage, except such coverage required by Federal law, during such quarter, whether or not under a State plan (or waiver of such plan) under this title or under another program established by the State, and regardless of the source of funding for such coverage, to an alien who is not a qualified alien and is not such a child or pregnant woman.

• The section prohibiting "gender transition services" from being covered as an Essential Health Benefit (EHB) includes a pretty lengthy list of procedures which wouldn't be allowed; they actually spend 5 pages of the 32-page bill discussing them, and besides the more obvious ones, they even include vasectomies, tubal ligations and hysterectomies under the title "PREVENTING WASTEFUL SPENDING."

• They then spend another 5 pages or so discussing the exact same lengthy list of procedures as being prohibited for Medicaid and CHIP.

• They even include things like "Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosthesis," although they did make sure to clarify that this is only "when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex"

So, y'know, at least cis women will still be allowed to get breast implants, which I'm sure will come as a huge relief to every heterosexual Republican man.