The Health 202: Here's how Cassidy and Graham rejiggered their Obamacare overhaul

The Washington Post

Sens. Bill Cassidy, R-La., and Lindsey Graham, R-S.C., will serve up a new version of their bill overhauling Obamacare on Monday, even as the whole grand effort appears headed for a meltdown. The new version still kind of looks the same as the old one. But it apportions bigger slices of federal health spending to the states of key senators who were leaning against -- or outright opposed -- to the original bill, endangering its success.

If you read the updated bill, which was leaked Sunday night to The Washington Post and other news outlets, it's pretty clear which senators Cassidy and Graham are playing to. A state-by-state summary claims Alaska would get 3 percent more funding, Arizona would get 15 percent more funding and Maine would get 43 percent more funding from 2020 and 2026 compared to current law.

Senators from all three of those states - Lisa Murkowski, John McCain and Susan Collins - had backed away from the bill in recent days. McCain indicated on Friday he'd oppose the bill because it wasn't going through regular order, while Collins and Murkowski said they want to better understand how it would affect their own states.

With Sen. Rand Paul, R-Ky., still insisting he won't back the bill, nabbing two of those three senators is crucial. Senate Republicans have just five days left to pass a measure repealing and replacing big parts of the Affordable Care Act. Their opportunity runs out on Oct. 1, when the budget reconciliation bill around which they'd based their entire strategy expires.

Acutely aware of the stakes, Senate GOP leadership and the White House are engaged in an all-in effort to rally the votes. But it's far from clear that they can get all but two Republicans to swallow this latest Cassidy-Graham iteration.

 

The plan was distributed among Republicans late Sunday. Aides to Murkowski and Collins did not immediately comment. Some Republicans close to the process have long counted Collins as an eventual "no," predicting that little could be done to the bill to change her mind. On Sunday night, some were once again privately pessimistic the changes would convince her to vote yes.

McCain is unlikely to bite. Even if the Senate Finance Committee considers Cassidy-Graham 2.0 in its high-profile health-care hearing Monday afternoon, there wouldn't be nearly enough time for the Congressional Budget Office to score it before a vote this week. Lawmakers do expect an analysis from the CBO Monday, but it will be based on the first version of Cassidy-Graham. And that's a far cry from the "regular order" McCain has called for.

But Cassidy and Graham, who have argued that Republicans must pass a bill repealing much of the Affordable Care Act or face serious retribution from their core voters in next year's midterms, are pressing forward. They will present their new bill as more equally distributing federal health-care spending among the states, so that no one state faces a big funding cliff.

The duo is still taking the same basic approach to revamping the ACA: The bill gathers its subsidies for private coverage and its Medicaid expansion, lumps together all of that spending, cuts it somewhat, and redistributes it to states in the form of block grants.

Under the first Cassidy-Graham bill, that would have resulted in a median change of 11 percent less funding for states that expanded Medicaid and 12 percent more for states that didn't, according to an analysis by the nonpartisan Kaiser Family Foundation. But there was a wide variation in the block grant funding; Mississippi would get 148 percent more relative to current law, while New York would get 35 percent less from the federal government, Kaiser had estimated.

The new version doesn't change the total sum of money the federal government would spend on the block grants from 2020 to 2026. Instead, it tries to smooth out the formula in what its sponsors hope is an effort to put states on a more equal footing. But the new version also creates some winners and losers: South Dakota would see the largest funding increase (88 percent) while Oregon would lose the most federal funding (17 percent).

--Let's look at Alaska and Maine. Kaiser had estimated the first version of Cassidy-Graham would result in 8 percent less block grant funding for Alaska; Republicans claim that under their latest bill Alaska would get 3 percent more. Kaiser had also estimated that Maine would get 8 percent more under the initial measure; it would get 43 percent more under the revised version of the bill, according to the GOP documents.

But let's also throw in an important caveat here: The estimates that Cassidy and Graham will publicly release Monday make some assumptions that independent analysts say are rather disingenuous.

For one thing, the state funding estimates don't take into consideration the bill's additional cuts to regular Medicaid spending. If those cuts were considered, it would be clear that states like Alaska and West Virginia would still be losing out on federal funds overall. And the GOP estimates also assume that states would slash their own funding for coverage and then factor that into the final number as "state savings."

Of course, opponents of Cassidy-Graham noted these things -- and kept sharply criticizing the bill overall -- Sunday night and into the early morning hours. Reporters also pointed out how the Republican estimates could be misleading:

From the Wall Street Journal's Michelle Hackman who tweeted:

"

The Graham-Cassidy state-by-state numbers folks are citing tonight

1) were produced by HHS

2) do not factor in significant medicaid cuts"

 

From the Center on Budget and Policy Priorities's Jason Leibenluft who tweeted:

"Seriously, folks: these #'s floating around don't even include the cap to Medicaid program (was $1 trillion cut from '20-'36 in prior draft)"

 

Will this latest Obamacare repeal recipe rise - or burn again? Keep your eyes on the oven.

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The new Cassidy-Graham bill also makes a play for the votes of Sens. Ted Cruz of Texas and Mike Lee of Utah by giving states more ability to duck federal insurance regulations. States could potentially lift existing caps on out-of-pocket costs, allowing insurers to offer leaner insurance policies that appeal to healthier consumers who want lower monthly premiums.

However, the Senate parliamentarian may rule that lifting ACA regulations in this manner isn't closely enough tied to federal health spending to go in the budget reconciliation vehicle Republicans are using.

Furthermore, many are skeptical that someone like Cruz, who has made repealing Obamacare a key part of his entire Senate term, would be the vote to sink the whole thing. But Cruz made a threat in that direction Sunday, when he said at the Texas Tribune Festival that Cassidy and Graham don't have his vote, or Lee's either.

 

 

-- In a popularity contest with Obamacare, the Cassidy-Graham health-care bill would lose, big time. That's according to a Washington Post-ABC News poll released Friday finding that roughly twice as many people strongly prefer current law to the GOP plan, 42 to 22 percent.

These aren't necessarily gut reflexes, either, because the poll described three aspects of Cassidy-Graham to voters before asking what they prefer: its elimination of the requirement for nearly all Americans to have health insurance, the phasing out of federal funds to help lower- and moderate-income people buy health insurance, and letting states replace federal rules on health coverage with their own rules.

A few more takeaways from the poll:

--Fifty-six percent of respondents said they prefer the Affordable Care Act to Cassidy-Graham; 33 percent said they prefer Cassidy-Graham over the ACA.

--There's a strong partisan divide; 85 percent of Democrats said they prefer the ACA to the GOP plan; 66 percent of Republicans said they prefer the GOP plan.

--Among independents, 54 percent said they prefer the ACA while 35 percent said they prefer Cassidy-Graham.

Sunday night, President Trump left open the possibility that Cassidy-Graham might not be successful despite likely plans to vote on it this week (McConnell folks have said Wednesday is the target), my colleague Abby Phillip reports.

"Eventually we'll win, whether it's now or later," Trump said as he prepared to board Air Force One to return to Washington after spending the weekend at his golf resort in Bedminster, New Jersey.

Trump lamented that Republicans still have reservations on health-care even though the bill "happens to be particularly good" for their states.

"I've been watching for seven years as the Republicans have been saying repeal and replace," he said. "My primary focus, I must tell you - and has been from the beginning as you can imagine - is taxes...I believe we will be successful in the largest tax cut in our country's history."

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