If you feel like you’re getting whiplash just from trying to follow the healthcare policy debate in Washington, you’re not alone; the hits in this saga have been coming seemingly nonstop. After saying the federal government would no longer pay certain subsidies that make the insurance marketplace work, President Trump at first seemed to support a bill that would create short-term stability. But that was yesterday. Today, he’s apparently changed his mind and is now against it.
There’s been a lot going on in healthcare policy in recent weeks; it seems like one of the many unrelenting drumbeats of 2017. But the TL;DR of where we stand today with healthcare is:
The payments are a critical part of making the ACA work. The federal government provides cost-sharing subsidies (CSRs) to insurers to offset certain expenses incurred by health plans. Insurers receive those payments to guarantee that co-pays and deductibles for low-income Americans buying coverage on the exchange can stay low.
Cut the CSRs, and the insurers have to make up the money somewhere. And that “somewhere” is the consumer’s pocket. Absent the subsidies, premiums, co-pays, and deductibles all shoot upwards — with the effect of utterly destabilizing the individual marketplace.
And that brings us to today, when two things at once are going on.
The White House Suddenly Hates Bipartisan Bill
Trying to figure out the White House’s strategy at any given moment in 2017 is, well… let’s be diplomatic and call it a challenge.
The day the Alexander-Murray proposal was announced, the President seemed to be in favor of it. He told reporters, “Yes, we have been involved,” adding:
Lamar [Alexander] has been working very, very hard with the Democratic, his colleagues on the other side. And Patty Murray is one of them in particular.
And they are coming up and they are fairly close to a short-term solution. The solution will be for about a year or two years. And it will get us over this intermediate hump, because we have, as you probably know — we have — either have the votes or we are very close to having the votes. And we will get the votes for having really the potential of having great health care in our country.
So they are indeed working, but it is a short-term solution, so that we don’t have this very dangerous little period.
However, President Trump this morning on Twitter made very clear his personal opinion of the bill has shifted, saying that although he is “supportive of [Sen.] Lamar [Alexander] as a person & also of the process,” he cannot support “bailing out” insurance companies who have “made a fortune” under the ACA.
I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co's who have made a fortune w/ O'Care.
— Donald J. Trump (@realDonaldTrump) October 18, 2017
That’s a pretty significant shift, and it even surprised the Senators involved.
“Trump completely engineered the plan that we announced yesterday,” Alexander told Axios about the bill. “He wanted a bipartisan bill for the short term.”
Heading to Court
Meanwhile, the coalition of attorneys general who are suing the administration have also asked the courts to intervene.
New York Attorney General Eric Schneiderman and California Attorney General Xavier Becerra bothannounced today that the coalition was seeking an injunction to put Trump’s policy change on hold and make the payments continue.
In the petition [PDF], the attorneys general asked the court “to enter a nationwide temporary restraining order and preliminary injunction requiring [the federal government] to continue making the cost-sharing reduction payments required by the [ACA] pending judicial resolution of this action.”
In other words, the AGs are asking the court to maintain the current status quo — where the payments exist — until such time as the lawsuits are decided one way or the other, which can take years.
“This is no longer about a campaign promise or a punchline. The Trump Administration is willingly breaking the law by refusing to make required payments that keep healthcare affordable for millions of Americans. It is taking active steps to sabotage the Affordable Care Act,” Becerra said in a statement.
Scheiderman echoed the sentiment, saying, “President Trump’s abrupt move to cut these subsidies is reckless, dangerous, – and illegal.”
He added, “We won’t stand for it – and we’re moving to block these dangerous cuts before they do any more harm.”
Senate Traffic Jam
There are a heap of other healthcare proposals also floating around in the Senate as we speak.
There’s the single-payer, Medicare-for-all proposal co-signed by nearly two dozen Democrats out for consideration. Democratic Sens. Tim Kaine (VA) and Michael Bennet (CO) also just introduced a bill proposing to add a public option that consumers could buy into through the marketplace.
But Senate Majority Leader Mitch McConnell has the privilege of setting the chamber’s agenda. So even if a bill actually has enough bipartisan support to move through a committee and pass a vote, it won’t see the light of day if leadership doesn’t want to let it.
The Washington Post reports that the Alexander-Murray proposal stalled out in the Senate almost immediately, with “discord” swiftly “casting the plans’ viability into serious doubt.”
House Speaker Paul Ryan joined Trump in his criticism of the proposal, Politico notes, which further limits its odds of success (a bill has to pass both the House and the Senate to become law).
With Congress either unwilling or unable to take action, that leaves the ball in the court’s court, to either approve or deny the states’ request for an injunction as a next move.
Smaller cable companies say they want to save you money, but they can’t. Why not? Comcast won’t let them.
At least that’s what the American Cable Association — an industry group representing all the little pay-TV companies that haven’t been bought by Comcast…yet — said in an Oct. 10 filing [PDF] with the Federal Communication Commission.
The ACA claims that Comcast forces smaller providers to carry a slew of NBCUniversal channels, effectively preventing these companies from offering their customers so-called “skinny” bundles that cost less and include fewer channels you don’t watch anyway.
The comments, submitted as part of the FCC’s annual review of competition in the pay-TV industry, highlight how Comcast’s wide array of assets can negatively affect competition among cable providers.
Putting Up Restrictions
ACA argues that many smaller cable companies are trying to offer customers inexpensive bundles that allow users to break up with large, more expensive cable companies, like Comcast.
But those big companies — described as multichannel video programming distributor networks or MVPD — aren’t having it. Instead, they’ve found ways to force the smaller companies to include their owned networks, effectively increasing the costs of skinny bundles, defeating the entire purpose.
“Many consumers that want to opt out of the big cable bundle in favor of a less expensive alternative are gravitating to a bundle that includes just the basic cable tier (essentially local TV stations) plus broadband Internet access and then relying on over-the-top video services to gain access to a more limited amount of cable programming more narrowly tailored to their specific interests,” ACA President and CEO Matthew M. Polka, said in a statement.
For instance, according to the filing, Comcast’s ownership of NBC Universal means the company controls “access to significant programming that its rivals must have access to in order to compete with it.”
Comcast’s must-have programming includes local television stations, cable channels, and regional sports networks.
The ACA claims that Comcast doesn’t want one of these elements to feel left out, so when a smaller company wants to offer customers local television stations or NBC-owned cable channels, the larger provider will require the company to offer sports, pushing up the price of the bundle.
“Denying a rival access to even one of these three categories of programming would threaten an [company’s] ability to compete, as the Commission has recognized,” ACA writes. “Thus, without a doubt, program access protections administered by the Commission continue to be necessary and important to protect competition and consumers.”
The group claims that Comcast, through its licensing agreements with regional sports networks, has unilaterally decided that ACA members should no longer be able to sell the basic broadcast service tier with broadband internet.
As a result, ACA claims that an MVPD must either raise the price of a broadcast basic tier or stop offering a true basic tier/broadband bundle that doesn’t induce a large number of costly cable networks.
Polka notes in a statement that this scenario shows that Comcast is standing in the way of ACA members that want to help customers “escape the burdens of the big and expensive expanded basic bundle of channels.”
Only Gonna Get Worse
ACA warns that unless the FCC steps in, things will only get worse in the near term, pointing to the impending merger between AT&T and Time Warner, which will result in another must-have block of programing under the control of a MVPD.
Additionally, the upcoming Jan. 2018 expiration of program access conditions placed on the Comcast-NBCU merger could make it even more difficult and expensive for smaller companies to offer Comcast’s networks.
“At an absolute minimum, the Commission must continue to vigorously enforce program access rules to provide at least some minimum level of protection to competition between MVPDs,” ACA writes.
The Commission should also immediately open a proceeding to determine if there is a need to extend or renew the Comcast-NBCU merger program access conditions.
As for Comcast, the company tells DSLReports that it’s just doing business.
“NBCUniversal negotiates in good faith with all of its distribution partners with the goal of making programming available to as many viewers as possible on fair market terms that are consistent with what other programmers offer,” a rep said.
CHICAGO (CBS) — Illinois’ junior U.S. Senator is among those highly critical of President Donald Trump’s Executive Order ending federal payments to health insurance companies under the Affordable Care Act, also known as Obamacare.
Senator Tammy Duckworth says President Trump’s order ending the subsidies for health insurance marketplaces is going to push many people out of being able to afford the healthcare they need.
“The subsidies help keep the cost low so that we could actually afford the health plans that are out there,” said Duckworth. “What will happen is when the subsidies go away, the cost of the healthcare plans will go up and they will become unaffordable,” she said.
Duckworth says the President should pay attention to the vast majority of Americans and consider their needs. She calls his actions shortsighted at best.
(AP) — Senate Republicans will not vote this week on the latest, last-ditch effort to repeal and replace President Barack Obama’s Affordable Care Act.
That’s the word from senators as they emerged from a closed-door meeting on Tuesday. Sen. Jeff Flake of Arizona shook his head and said “no” when asked about plans for a vote.
The setback marks the end for the latest drive to overturn the law, a promise the GOP has made to voters for seven years.
The latest iteration of the bill was sponsored by Sens. Bill Cassidy and Lindsey Graham, but opposition from at least three Republican senators in the narrowly-divided Senate sunk the measure’s chances. Democrats were unified in their opposition.
A new analysis finds that 34 states and Washington, D.C., would lose money under the newest version of the Republican health care bill.
This is despite last-minute changes to the legislation.
Overall, states would get $205 billion less in federal health care money from 2020-2026, according to the analysis from consulting firm Avalere Health, which was released Tuesday.
States that expanded Medicaid to cover low-income adults, as well as those where lots of residents have signed up for subsidized private health insurance, were more likely to be losers under the Graham-Cassidy bill.
The latest changes soften the magnitude of the funding shifts, but the end result remains similar.
Half the 30 states President Donald Trump won last year would lose money.
Losses would grow over time. Sixteen states would gain money.
President Donald Trump says he’s “disappointed in certain so-called Republicans” who have opposed the latest GOP attempt to repeal former President Barack Obama’s health care overhaul.
Trump tells reporters at the White House that “we’ll see what happens” on whether the Senate will vote on the plan, which has suffered from Republican defections.
Trump says he’s “very disappointed by a couple of senators,” adding, “We don’t know why they did it.”
The president says “at some point there will be a repeal and replace” of the health care law. But Republican leaders in the Senate are conceding that their prospects for repealing the law are dismal.
Senate Majority Leader Mitch McConnell says the partisan debate over the country’s health care system will “certainly continue.”
The Kentucky Republican spoke as he tries to decide whether to hold a vote on the latest GOP bill repealing President Barack Obama’s law. That measure seems almost certain to be defeated if a roll call were held.
The Republican legislation would transform much of “Obamacare’s” spending into grants states could spend on health programs with few constraints.
McConnell called that proposal a “stark contrast” to a plan by Vermont independent Sen. Bernie Sanders. That measure is backed by many Democrats and would create government-run health insurance.
McConnell says Sanders’ plan would “rip” health insurance from people. He called the issue an important debate and said, “It’s one that we’ll certainly continue.”
The White House says it believes a Senate health care bill that appears headed for defeat is “still good legislation.”
Spokeswoman Sarah Huckabee Sanders says the White House is “fully committed” to improving the health care system and that the Senate bill would do that.
With no Democratic support expected, three “no” votes from Republicans would appear to doom the bill. Republicans control 52 Senate seats and Sens. Susan Collins of Maine, John McCain of Arizona and Rand Paul of Kentucky have said they will not vote for the bill.
Sanders held out hope that opposing lawmakers might change their minds, or that undecided senators — like Lisa Murkowski of Alaska — will support it.
Senate Republican leaders have conceded that prospects for passing the measure this week appear dismal.
Republican Sen. Susan Collins’ decision to oppose the GOP push to repeal President Barack Obama’s health care overhaul leaves the effort all but dead. Even party leaders concede that their prospects are dismal.
South Dakota Sen. John Thune, the No. 3 GOP Senate leader, says reviving the push would be a heavy lift.
Thune made the comment after Collins joined a small but pivotal cluster of Republicans saying they’re against the measure.
GOP Sens. John McCain of Arizona, Rand Paul of Kentucky and Ted Cruz of Texas are also against the legislation, though Cruz aides say he might back it if changes are made. Alaska’s Lisa Murkowski is a Republican who’s undecided.
With their narrow Senate majority, defections by three GOP senators would doom the bill.
The surprise hit show of the summer, “No, Seriously, What The Heck Is Going On With Congress And Healthcare, Though?” is back for the fall season. And in our latest episode, Republican leadership in the Senate is making last-minute changes to the latest Affordable Care Act replacement bill in a targeted effort to win over reluctant GOP lawmakers before their Sept. 30 deadline.
The latest draft [146-page PDF] of the current ACA replacement bill working its way through the Senate is out this morning, and it includes some very specific changes intended to draw support from holdout Senators.
Sens. Lindsey Graham (SC), Bill Cassidy (LA), Dean Heller (NV), and Ron Johnson (WI) released the latest proposal to reverse the ACA earlier this month.
They call it the GCHJ Amendment, but everyone else calls it Graham-Cassidy — and it’s not quite a regular bill. It’s technically a budget resolution, which means that it would only need 51 votes to pass the Senate. It also means there is a strict deadline of Sept. 30, when the federal fiscal year ends, for the Senate to okay the bill. After that window closes, it would have to be treated like a traditional piece of legislation and would need a currently-impossible 60 votes to move on to the House.
Additionally, if Graham-Cassidy does pass the Senate by the deadline, the House would not be able to change a single word on it, as that would require the bill going back to the Senate once again for approval. So if the Senate passes this bill, it’s an all or nothing proposition for the House.
The Senate Finance Committee will be holding a hearing on Graham-Cassidy this afternoon (Monday, Sept. 25), and a spokesperson for Senate Majority Leader Mitch McConnell has confirmed that McConnell does indeed intend to bring the proposal to the Senate floor for a vote before the cutoff.
That means anything that happens needs to happen basically within the next five days.
The Graham-Cassidy proposal is enormously unpopular — and the speed with which it’s flying through the Senate doesn’t help.
Because of the end-of-month deadline, the non-partisan Congressional Budget Office will not have time to issue a proper score on the bill before the Senate has to vote on it. At best, the CBO can release a high-level report with minimal information about the bill’s potential impact on the deficit — a report that’s expected early this week.
Several independent, non-partisan third-party groups have released first-pass analyses sussing out what the effects of Graham-Cassidy would likely be, however, and all of them find tens of millions of Americans would lose insurance coverage amid massive slashes to Medicaid funding in the majority of states.
READ MORE: HOW THE LATEST ACA REPEAL PLAN COULD AFFECT YOU
It’s not just the general public that opposes the bill, although so far two different polls have both found that, at most, 20-45% of the nation supports Graham-Cassidy, and significant majorities oppose it.
More importantly, though, basically every single stakeholder you can possibly think of has come out in opposition to the bill. That includes groups representing the nation’s schools, doctors, nurses, patients, and hospitals — as well as the groups that represent the health insurance industry.
Most unfortunately for Graham, Cassidy, and Senate Majority Leader Mitch McConnell (KY), the list of people who don’t like the Graham-Cassidy proposal includes an increasing number of Republican Senators.
The main reason for slamming healthcare reform through as a budget resolution is that doing so means it only needs a simple majority — 51 votes — to pass. (A standard bill is subject to procedural measures that can mean it needs 60 votes in order to pass.)
There are 52 Republican Senators, plus Vice President Mike Pence can cast a tie-breaking 51st vote as needed. That means McConnell can afford to have two members of his party peel off, but not three.
That’s what happened in July, on the last round: Sens. Susan Collins (ME) and Lisa Murkowski (AK) were known “no” votes on the bill, and then Sen. John McCain (AZ) cast a surprise late-night third “no” vote, dooming the proposal.
Late last week, McCain came out as a strong, unequivocal “no” on the proposal, saying, “I cannot in good conscience vote for the Graham-Cassidy bill.”
Sen. Rand Paul (KY) has also been a vocal opponent of the proposal on the grounds that it doesn’t go far enough toward being a true repeal. However, it’s worth noting that he said the same about the July bill, and yet in the end supported it anyway.
Sen. Ted Cruz (TX) announced his opposition over the weekend, saying that the proposal, as it currently stands, does not have his backing and likely does not have the support of his colleague Sen. Mike Lee (UT) either. However, like Paul, Cruz and Lee both opposed the July bill until they didn’t anymore, and cast their votes in favor.
That leaves everyone watching Murkowski and Collins.
Collins has not yet stated formal opposition to the bill, but is considered vanishingly unlikely to end up supporting it. Murkowski, however, has remained an unknown, stating neither support nor opposition on the record.
Murkowski and Collins objected to the July bill in large part over its draconian cuts to Medicaid funding and women’s healthcare. The first draft of Graham-Cassidy also put in place massive cuts to Medicaid funding, but not across the board. Rather, some states would benefit, and others would lose out.
Alaska was one of the “loser” states under the original bill, standing to suffer a 38% cut in Medicaid funding under Graham-Cassidy as opposed to the current law. So one of the changes is to sweeten the pot for Alaska specifically, to try and curry Murkowski’s vote.
Other provisions would steer more funding to Arizona and Kentucky, Politico notes — the states represented by McCain and Paul, respectively.
Still more changes are designed to apply to the holdouts from the more conservative side of things — that’d be your Paul, Cruz, and Lee.
Those changes include allowing states to split the sick and the healthy into multiple “risk pools,” which means the cost of obtaining insurance if you have a pre-existing condition (or look like you might develop one) would skyrocket to potentially unattainable levels.
States would also be allowed to decide what the out-of-pocket cap (if any) should be, and how much insurers can charge anyone with a pre-existing condition. Nor would states need to seek formal waivers for these or any other changes, instead simply submitting a plan saying that “adequate and affordable” coverage will be available.
The Kaiser Family Foundation’s Larry Levitt described the update as, “in effect, federal deregulation of the insurance market.
Our colleagues down the hall at Consumers Union agreed. “This bill is an even harsher version of the previous failed proposals that were overwhelmingly rejected by Americans. It is not only a repeal of the Affordable Care Act — threatening key consumer protections and coverage requirements that ensure those with preexisting conditions have access to meaningful care — but also a historic undercutting of the Medicaid program,” said CU’s Betsy Imholz. “No one time buyout, carve out, or ‘fix’ can address these problems.”
The last-ditch proposal to effectively repeal the Affordable Care Act remains deeply unpopular, even while Senate Republicans try to rally the votes to make it happen. And in the midst of all that politicking, a new federal analysis shows that several of the states whose Senators’ votes leadership is trying to curry could be badly hurt by the bill.
Massive Medicaid Cuts
According to an estimate [PDF] from the Centers for Medicare and Medicaid (CMS) that compares current Medicaid funding levels with what would be available under the proposed Graham-Cassidy repeal bill, more than half of the states would see between funding cut by 5%-10% by 2020.
Looking ahead even further, by 2027, 31 states would see a drop in Medicaid funding, with nearly half the country (24 states) experiencing funding decreases of 20% or more.
Those that would suffer the deepest cuts are Connecticut and Maryland, with projected reductions of 52% and 51% respectively.
Others in this group would be Alaska, Arkansas, California, Colorado, Delaware, D.C., Hawaii, Kentucky, Louisiana, Massachusetts, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Oregon, Pennsylvania, Vermont, Washington, and West Virginia.
On the flip side, a handful of states — all of them among those that have continued to reject the Medicaid expansion and its related federal funds under the ACA — would see huge increases in Medicaid funding.
By 2020 alone, South Dakota would see a 282% increase in funding, followed by a 109% bump in Wyoming, a 59% increase in Alaska, a 55% lift in Montana, 52% for North Dakota, and increases between 10 and 30% in Alabama, Georgia, Kansas, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas, and Utah.
Shift the outlook to a ten-year one, and the disparity becomes even more stark and shocking.
By 2027, CMS estimates, the biggest winners under Graham-Cassidy would be Mississippi residents, who would see a 347% increase in Medicaid funding.
Kansas, with a 234% increase, would also do well enough for itself, and Texas (210%), Tennessee (194%), Alabama (192%), and South Dakota (162%) would also see major funding improvements.
The National Association of Medicaid Directors, which represents the directors of Medicaid programs for all 50 U.S. states, D.C., and all U.S. territories, issued a statement asking the Senate not to move forward on Graham-Cassidy, and instead, to “revisit the topic of comprehensive Medicaid reform when it can be addressed with the careful consideration merited by such a complex undertaking.”
Best Case Scenario?
Axios, which was the first to report on the CMS estimates, notes that these sharp cuts are the are the least bad projection so far, calling the CMS numbers “rosier than other estimates.”
In part because of the projected cuts to Medicaid, several independent analyses are projecting that Graham-Cassidy would cause at least 32 million Americans to lose coverage altogether in the coming decade.
READ MORE: Everyone hates Senate Obamacare repeal bill; Senate plans vote anyway
The Brookings Institute is the most recent think tank to issue a study on the projected outcomes of Graham-Cassidy. The Brookings report finds that in the immediate short term (2018-2019), 15 million people would lose health care coverage.
But It Might Be Doomed Anyway
That’s all the bad news. Here’s the good: It’s looking less likely today than it has all week that Graham-Cassidy will actually come to a vote or become law.
The Graham-Cassidy bill is technically a budget resolution amendment, meaning that it can squeak out of the Senate with a simple majority — 51 votes — as long as it does so by Sept. 30. There are currently 52 Republican members of the Senate, plus Vice President Mike Pence can cast a tie-breaking vote as needed, so the math says Senate Majority Leader Mitch McConnell can only afford to lose three votes.
Sen. Rand Paul (KY) has repeatedly and emphatically gone on the record as a “no” to Graham-Cassidy. It’s worth noting that he also opposed the July bill at first, before voting on it anyway, but for now at least folks who are tallying up the votes count him out.
Sens. Lisa Murkowski (AK) and Susan Collins (ME) were two of the three holdouts over the Senate’s July bill. Both opposed it in part due to its severe cuts to Medicaid funding. Although neither has officially yet gone on the record as a “no” to Graham-Cassidy, Collins is publicly leaning against it. Republicans, meanwhile, have been strongly pressuring Murkowski to vote for the bill, but she has as yet not indicated any support for it.
That means all eyes have been on Arizona Senator John McCain, whose dramatic, surprise late-night vote spelled the doom of the Senate Republicans’ last ACA repeal effort in July.
Friday afternoon, McCain issued a statement definitively indicating his opposition to the proposal.
“I cannot in good conscience vote for the Graham-Cassidy bill,” McCain said. “I believe we could do better working together, Republicans and Democrats, and have not yet really tried. Nor could I support it without knowing how much it will cost, how it will affect insurance premiums, and how many people will be helped or hurt by it.”
There won’t be time for the Congressional Budget Office to issue an analysis on the bill before the end-of-month deadline, McCain noted, so the Senate “won’t have reliable answers to those questions.”
Hill-watchers generally suspect that McCain’s firm no will give political cover for Collins and Murkowski, at least, to join him — killing the bill.
In the meantime, however, the Senate Finance Committee is planning a hearing on the Graham-Cassidy proposal for Monday afternoon, Sept. 25.
After a politically chaotic summer where their first attempt met a dramatic late-night demise, Republican members of the Senate are mounting one last effort to repeal the Affordable Care Act. Basically every major stakeholder in the country has announced its opposition to the new bill, but the Senate is racing to squeeze in a vote before a hard deadline at the end of the month just the same.
Sens. Lindsey Graham (SC), Bill Cassidy (LA), Dean Heller (NV), and Ron Johnson (WI) released the latest proposal to reverse the ACA late last week.
The Graham-Cassidy bill, as it is generally known, is actually technically a budget resolution — so for procedural reasons, it’s got a hard make-or-break Sept. 30 deadline.
There is a hearing on Graham-Cassidy scheduled for Monday, Sept. 25, and a spokesperson for Senate Majority Leader Mitch McConnell confirmed to Politico that McConnell does indeed intend to bring the proposal to the Senate floor for a vote before the cutoff.
That means, among other things, that the non-partisan Congressional Budget Office will not have time to issue a proper score on the bill before the Senate has to move on it.
However, several independent, non-partisan third-party groups have released analyses in the last day sussing out what the effects of Graham-Cassidy would likely be.
The Kaiser Family Foundation released a report looking at the effect on Medicaid funding to the states the Graham-Cassidy bill would have. Overall, KFF estimates that 35 states plus D.C. would lose Medicaid funding, with states that accepted a Medicaid expansion as part of the ACA losing an average of 11% of their funds.
READ MORE: HOW THE LATEST ACA REPEAL PLAN COULD AFFECT YOU
The Commonwealth Fund also issued a report, estimating that at least 32 million people who currently have coverage would lose it under Graham-Cassidy. And based on an analysis from the Center for Budget and Policy Priorities, Fitch Ratings has determined that Graham-Cassidy would be “more disruptive” than even other ACA repeal proposals.
Even the Republican Senators championing the bill don’t seem particularly enamored of it, Vox notes — they’re just planning to vote for it because it’s the bill they’ve got, they all ran on “repeal and replace,” and time is running out.
In the last week, dozens of groups representing basically everyone you can think of — retirees, children, doctors, nurses, hospitals, patients, and even insurers — has come out in opposition to the bill. You name a stakeholder, and they’re probably against it.
The health insurers are the big moneybags corporations in the room, when it comes to healthcare — and they are not happy with the Graham-Cassidy proposal.
America’s Health Insurance Plans, the industry’s largest trade and lobbying group, sent a letter [PDF] to McConnell, as well as Senate Minority Leader Chuck Schumer, outlining some of the ways in which they expect Graham-Cassidy would hurt consumers, and asking the Senate to approach healthcare differently.
“The Graham-Cassidy-Heller-Johnson proposal… would have real consequences on consumers and patients by further destabilizing the individual market; cutting Medicaid; pulling back on protections for pre-existing conditions; not ending taxes on health insurance premiums and benefits; and potentially allowing government-controlled, singly payer healthcare to grow. … We cannot support this proposal.”
AHIP is joined by the Blue Cross Blue Shield Association, which said in a statement that it has “significant concerns” with the Graham-Cassidy bill, due to its Medicaid cuts and “provisions that would allow states to waive key consumer protections, as well as undermine safeguards for those with pre-existing medical conditions.”
Kaiser Permanente CEO Bernard J. Tyson also opposed Graham-Cassidy in a statement, saying, “At Kaiser Permanente, we believe that changes to our nation’s health care laws should increase access to high-quality, affordable care and coverage for as many people as possible. The Graham-Cassidy bill does not meet any of those tests.”
The American Medical Association, which represents physicians and medical students, wrote a letter [PDF] to the Senate opposing the bill.
“Unfortunately, the Graham-Cassidy amendment … violates the precept of ‘first do no harm,’ the organization’s CEO writes.
“Similar to proposals that were considered in the Senate in July, we believe the Graham-Cassidy amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care,” he continues. “We also urge the Senate to reject any other legislative efforts that would jeopardize health insurance coverage for tens of millions of Americans.”
The doctors are joined here by the nation’s registered nurses: The American Nurses Association is calling Graham-Cassidy “the worst healthcare bill yet,” and urging ANA members to contact their Senators in opposition.
Insurers aren’t the only giant corporate entity in healthcare; hospitals, too, are a booming (and increasingly concentrated) business.
The American Hospital Association — the national lobbying group representing, as you’d think, the interests of hospitals — issued a statement opposing Graham-Cassidy in no uncertain terms.
“We believe that coverage could be at risk for tens of millions of Americans under the Graham-Cassidy proposal,” AHA CEO Rick Pollack said. “This proposal would erode key protections for patients and consumers and does nothing to stabilize the insurance market now or in the long term. In addition, the block grant to provide support for the expansion population expires in 2026, thereby eliminating coverage for millions of Americans.”
“For these reasons,” Pollack concluded, “We oppose the Graham-Cassidy plan.”
Health and Medical Issue Groups
There are a large number of groups in the country dedicated to promoting the interests of patients and families impacted by certain medical conditions. Sixteen of the largest — including the American Cancer Society, the American Diabetes Association, the American Heart Association, the American Lung Association, the Arthritis Foundation, the March of Dimes, and the National Multiple Sclerosis Society — issued a statement opposing the bill.
“Affordable, adequate care is vital to the patients we represent. This legislation fails to provide Americans with what they need to maintain their health,” the groups said.
They added, “This bill would limit funding for the Medicaid program, roll back important essential health benefit protections, and potentially open the door to annual and lifetime caps on coverage, endangering access to critical care for millions of Americans. Our organizations urge senators to oppose this legislation.”
Schools, Educators and Civil Rights Groups
A massive coalition of more than 70 groups representing schools, teachers, education administrators, civil rights advocates, and disability rights’ advocates sent a letter [PDF] to the Senate expressing opposition to the bill.
The coalition is “concerned that the Graham-Cassidy bill jeopardizes healthcare for the nation’s most vulnerable children: students with disabilities and students in poverty,” the letter reads.
“The projected loss of hundreds of billions in federal Medicaid dollars will compel states to ration health care for children,” as well as cutting off “basic health screenings for vision, hearing, and mental health problems for children,” the coalition explains. “Considering these unintended consequences, we urge a ‘no’ vote on Graham-Cassidy.”
The long list of signatory groups includes the ACLU, the National Association of Elementary School Principles, the National Association of Secondary School Principals, the National Association of Social Workers, the National Association of State Boards of Education, the National Education Association, and the United Way.
The AARP has published a report finding that Graham-Cassidy would endanger coverage for older Americans, and sent a letter [PDF] to senators urging them to vote no.
“We are deeply concerned these cuts will endanger the health, safety, and care of millions of individuals who depend on the essential services provided through Medicaid,” the AARP notes. “Should this bill be brought to the Senate floor for a vote, we strongly urge all Senators to vote NO.”
A genuinely bipartisan group of states’ governors, including the top executives of Alaska, Colorado, Louisiana, Massachusetts, Montana, Nevada, Ohio, Pennsylvania, Vermont, and Virginia, also urged the Senate to reconsider. In a letter [PDF], the governors “Ask [the Senate] not to consider the Graham-Cassidy-Heller-Johnson amendment and [instead] renew support for bipartisan efforts to make health care more available and affordable for all Americans.”
And last but not least, we have comedian and late night host Jimmy Kimmel:
One of the reasons that the effort to repeal the Affordable Care Act met a dramatic late-night demise in July was the criticism that GOP lawmakers held no actual hearings on this matter that could directly impact many millions of Americans. As Republican senators look to make one last try at repeal before their clock runs out, legislators are finally holding their first, but ultimately pointless, public hearing on healthcare.
I’m just a bill…
Ordinarily a bill goes through an iterative process before it becomes law. The path goes something like this:
One or more Senators introduce it
The bill is then referred to relevant committee(s)
The committee(s) hold one or more hearings and markup sessions on bill, debating its merits and adding or subtracting language (amendments)
The final, amended bill passes committee by majority vote
The full Senate then votes on the bill after committees are done
That’s regular procedure. But when you go through the regular procedure, in the regular way, for a regular bill, you run the procedural risk of needing to have at least 60 Senators on your side in order to move forward.
That’s clearly not going to happen with ACA repeal proposals, which are universally unpopular with the Senate’s 48 Democrats (and Democratic-caucusing independents). So all of the the ACA repeal efforts have been moving through a process called budget reconciliation.
To put it briefly, budget reconciliation allows certain types of bills to be fast-tracked through the Senate with only a simple majority. Since Vice President Mike Pence holds the tie-breaker, the GOP need only get to 50 “yea” votes in order to pass the bill.
At the same time, this all has to happen by Sept. 30, which is the end of the federal government’s fiscal year. Any bill passed after that would have to go through the normal channels and would need the 60 votes to end debate in the Senate.
Out of the ordinary
The failed July bill did not go through any committee hearings, which was one of Sen. John McCain’s (AZ) key objections when he voted it down.
“We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people,” McCain said at the time. Other Senators also called for a return to “regular order” in the wake of the July mess.
And so, a hearing.
Sen. Ron Johnson (WI), one of the co-sponsors of the Graham-Cassidy bill, personally promised that the bill would get at least one proper committee hearing. He could bring it before his committee, he said: Homeland Security.
“I’m chairman of Homeland Security,” Johnson said. “If either the Finance Committee or [Health, Education, Labor and Pensions] Committee won’t hold a hearing, I’ll notice one this afternoon. We’ll hold a hearing on this prior to September 30th.” And he did indeed put a hearing on the Homeland Security calendar for Sept. 26.
If that sounds ridiculous to you, you’re right: The Homeland Security and Governmental Affairs Committee has nothing at all to do with healthcare or health insurance legislation. There’s no real overlap.
But Johnson’s political dare paid off: Sen. Orrin Hatch (UT), chair of the Senate Finance Committee, agreed to hold a hearing on the proposal on Monday, Sept. 25. The relevant testimony and witness list are yet to be determined.
“Senators have expressed a strong desire to examine the details of the Graham-Cassidy proposal through a public hearing,” Hatch said in a statement. “A hearing will allow members on both sides of the aisle to delve deeper into its policy and gain a better understanding of what the authors hope to achieve.”
The hearing, however, is largely for show — to tick a box and say they did it. Aside from a few wild cards, Senators’ minds are already made up along partisan and ideological lines.
And what do they hope to achieve?
The one leg up that the Graham-Cassidy bill has over McConnell’s summer attempts is that it’s not being hidden or kept secret. But other than that, it’s a very similar pile of cuts, likely to have consequences every inch as dire… if not worse.
The Congressional Budget Office, tasked with analyzing potential legislation to run the numbers on it likeliest outcomes, won’t have time to churn out a full, deep-diving report on the Graham-Cassidy proposal. However, it is expected to release a high-level, preliminary sketch early next week.
READ MORE: Senate may vote on latest Obamacare repeal bill without knowing how many people it will affect
Anyone with a pre-existing condition would be at risk for incessantly skyrocketing premiums under Graham-Cassidy, Vox reports. The non-partisan Center on Budget and Policy Priorities also finds that federal healthcare funding — to programs like Medicaid and individual subsidies — would be slashed by hundreds of billions of dollars over the next ten years.
The American Medical Association sent a letter [PDF] to the offices of McConnell and Senate Minority Leader Chuck Schumer (NY) asking the Senate to reject Graham-Cassidy because it “would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care.”
Other organizations voicing opposition include the AARP, the American Cancer Society, Cancer Action Network, the American Diabetes Association, the American Heart Association, the American Lung Association, the Arthritis Foundation, the National Health Council, and the March of Dimes, among others.
How’s that math?
There are 52 Republican Senators and one Vice President — so to get to 51 votes, McConnell can only afford to lose three.
An analysis by the numbers-minded folks at FiveThirtyEight concludes that 46 votes are a sure thing or a nearly sure thing right out of the gate. That leaves a couple of likely “no” votes and four “wild cards” to contend with.
Sen. Rand Paul (KY) has already gone on the record in opposition, both in various Tweets and in an op-ed for Fox News. Paul’s opposition comes from the far conservative side: He believes that Graham-Cassidy does not go far enough to remove all traces of the ACA from the world. However, Paul also originally had stringent objections to the July bill at first, before changing his mind and voting for it anyway — so it’s anyone’s guess where his vote would actually fall.
The same is true of Utah Sen. Mike Lee, who also initially opposed the July bill for being insufficiently conservative before then voting for it anyway.
Sen. McCain has indicated that he might be amenable to voting “reluctantly” in favor, but said his approval was contingent on whether the governor of Arizona felt the Graham-Cassidy would help or hate the people of that state. Gov. Doug Ducey put out a statement endorsing Graham-Cassidy on Monday, and so now McCain is considered more likely to go for it.
The other two holdouts in July were Sens. Susan Collins (ME) and Lisa Murkowski (AK). Both objected to deep cuts to Medicaid and other healthcare spending that would negatively affect the populations of their states — and since the new bill provides for cuts that are either equally as bad or worse, all eyes are on Collins and Murkowski to renew their objections once again.
Neither, however, has yet gone on the record with either full opposition or support. The Portland Press-Herald reports that Collins has “concerns” with the Graham-Cassidy proposal, particularly with regards to Medicaid.
Murkowski is also a long shot to bring on board, CNN reports, because the Graham-Cassidy proposal, as written, would likely be a losing proposition for Alaska overall. Alaska’s governor has come out against the bill.
But as Axios reports, the Trump Administration has gone all-in on trying to sway every single Republican Senator to support the proposal — and so we are once again, as a nation, on tenterhooks, waiting to see which way the breeze blows up on Capitol Hill in the coming days.
Senators Lindsey Graham (SC) and Bill Cassidy (LA), joined by Dean Heller (NV) and Ron Johnson (WI) on Wednesday released a new, last-ditch ACA repeal bill.
Graham and Cassidy actually first pulled together their proposal in July, while the Senate was foundering on the McConnell bill that eventually failed.
Most folks call this attempt the Graham-Cassidy bill, although the Senators’ offices are trying to make “GCHJ” happen. (It won’t.)
What does it do?
Although this bill [141-page PDF] takes a slightly different approach to repeal than the failed July bill, Graham-Cassidy still aims for several similar outcomes, including:
Repealing the individual mandate
Repealing the employer mandate
Permitting states to opt out of requiring insurers in their borders cover essential health benefits
Ends the Medicaid expansion
Replaces some Medicaid funding with block grants that states can use for whatever
An analysis from the non-partisan Center for Budget and Policy Priorities concludes that Graham-Cassidy would result in large cuts to federal funding for healthcare overall, without replacement. The bill would also hurt anyone with pre-existing conditions on the individual market, because of the way in which states would be able to opt out of benefits and coverage requirements.
Graham-Cassidy would “cause many millions of people to lose coverage, radically restructure and deeply cut medicaid, and increase out-of-pocket costs for individual market consumers, the CBPP concludes.
Our colleagues down the hall at Consumers Union agree. “Just like its predecessors, this plan would leave tens of millions uninsured, threaten key consumer protections and coverage requirements, and fundamentally alter Medicaid by drastically cutting funding and shifting billions of dollars of healthcare costs onto states and consumers,” CU’s Betsy Imholz said in a statement.
In short: it’s basically a new skin on the same set of policy proposals we all saw circulating earlier this year.
Is it actually going to happen?
Hill-watchers and Washington media largely consider Graham-Cassidy an unlikely long shot at best — but if watching Congress in 2017 has taught us anything, it’s: ¯_(ツ)_/¯
The math in the Senate is the same now as it was in July: Senate Majority Leader Mitch McConnell needs 50 members to vote in favor of something in order to get it to pass. (Vice President Mike Pence can cast a tie-breaking 51st vote as needed.)
That’s leading Republicans in favor of the bill to crow that they’re almost there, boasting that at least 47-49 members are already in line to vote for it.
But as we saw this summer with Sen. John McCain’s (AZ) dramatic late-night thumbs down, it’s that 50th vote that you can’t get by without.
There are 52 Republicans in the Senate, meaning that if three choose not to support the bill, it’s dead in the water. Sen. Rand Paul (KY) has already gone on the record as a “no.”
Sens. Susan Collins (ME) and Lisa Murkowski (AK) were the other holdouts over the Senate’s July bill. At the time, both cited objections to cuts in coverage and in Medicaid funding. Consdiering Graham-Cassidy promises equally dire cuts, it seems unlikely that either would suddenly be swayed — but unlikely is not the same as impossible.
That said, anything that did manage to get through the Senate would still have to get through the House before becoming law… and the clock is ticking. Because the procedural tactic Congress has been using to try and rewrite healthcare, budget reconciliation, has a deadline. Congress has to be completely done with any bill before the clock strikes midnight on Sept. 30.