Repealing the 2010 Affordable Care Act was at the top of Trump’s agenda long before he won the presidency, but his administration has found the task a bit trickier than expected.
Senate Republicans previously attempted to pass legislation repealing Obamacare back in July in a bill that media pundits like The Hill called “skinny” as it did not provide alternatives to the majority of the provisions in the ACA.
In a rather dramatic twist, Republican Senator and sometimes Trump-nemesis John McCain broke from his party and cast the deciding vote that killed the bill shortly after the midnight deadline.
The GOP has tried and failed on two other occasions to repeal the ACA since Trump assumed office in January. As a result, Republicans have started looking again at the provisions in the Graham-Cassidy-Johnson-Heller amendment, which was introduced earlier this year.
Bill sponsors Senators Bill Cassidy (R-LA), Lindsay Graham, (R-SC), Dean Heller (R-NV), and Ron Johnson (R-WI) re-introduced the legislation in September packaged in a budget reconciliation bill, and it was recently endorsed by President Trump.
Unlike previous attempts by the Trump administration to roll back the ACA, Graham-Cassidy does not repeal Obamacare. Instead, it simply alters certain key features in such a way as to undermine their intended purpose.
Here’s what you need to know about the Graham-Cassidy healthcare bill:
1. Graham-Cassidy Eliminates Medicaid Expansion & Introduces Funding Caps That Will Result In $215 Billion Worth Of Cuts By 2026
The Affordable Care Act of 2010 mandated that states expand Medicaid coverage to include all adults ages 18 to 65 whose incomes fall below 133% of the federal poverty line, regardless of health status.
However, in a surprising July 2012 decision, the U.S. Supreme Court subsequently declared the provision unconstitutional while at the same time upholding the constitutionality of the ACA itself.
Five of the court justices then collaborated to create a plan that would make Medicaid expansion voluntary for states without jeopardizing their access to existing federal healthcare funding. Since then, 32 states have opted to expand their Medicaid systems; the 18 holdout states are concentrated in the South and the Midwest.
Graham-Cassidy would eliminate the Medicaid expansion program and replace the current federal reimbursement model, which pays for a fixed share of all Medicaid expenses, with one that would fix state Medicaid funding based either on the number of enrollees, called per-capita funding, or an annual block-grant that bases funding on the number of eligible non-disabled, non-elderly adults and children.
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An analysis by D.C.-based health policy think tank Avalere estimated that the fixed funding would result in cuts of about $215 billion across 34 states by 2026 due to the redistribution of funding that would occur between the states that expanded Medicaid under the ACA and those that did not.
“The largest impact of the proposed bill would be the reallocation of federal dollars between states,” said Elizabeth Carter, a senior vice president at Avalere, adding that, “Medicaid expansion states and states that have enrolled a high number of people in insurance affordability programs would be most adversely impacted.”
Senator Cassidy himself acknowledged that the redistribution of funds would prove problematic: “We work hard, through a variety of mechanisms, to offset this loss,” he told Vox. The senator pointed toward a provision in the bill that allows states that see cuts to seek funding through the disproportionate share hospitals (DSH) program, which allots extra funding to hospitals that see a high number of uninsured patients.
However, critics say that redirecting state funding through the DSH program shifts the burden onto hospitals, and, according to health economist at Northwestern University Craig Garthwaite, is tantamount to “admitting that [Graham-Cassidy] is gonna increase the number of people who are uninsured and those people are still gonna go to the hospital.”
2. Graham-Cassidy Would Create a Waiver System in Which States Can Opt out of Key ACA Market Rules Like Pre-Existing Conditions & Mandated Coverage Areas
According to the Avalere analysis, Graham-Cassidy also sets up a waiver system for key provisions of the ACA that would allow states to opt-out of such market rules like the prohibition of medical underwriting, and mandated provision of essential coverage areas such as mental health, substance abuse, and maternity benefits.
Previous analyses by the Congressional Budget Office, according to Avalere, have “projected this flexibility to substantially increase costs of those individuals with significant medical costs.”
One of the key changes included in the ACA was that insurance companies were no longer permitted to refuse coverage to individuals based on pre-existing conditions, and basic coverage areas like maternity care were required in order for a plan to be included in the state marketplaces.
Cassidy has said that the state must prove they can “maintain adequate and affordable health insurance coverage for individuals with preexisting conditions” on any waiver application as a means of protecting sick people from over-inflated premiums. However, the legislation does not define what adequate and affordable coverage looks like in a post-Obamacare world.
3. Other Provisions Include Tax Breaks, Repeals, & No Abortion Coverage
On page 2 of the 150-page bill, Graham-Cassidy includes an amendment to a tax code that defines a “qualified health plan” according to the ACA. The amendment would disqualify plans that include “coverage for abortions (other than any abortion 12 necessary to save the life of the mother or any 13 abortion with respect to a pregnancy that is the 14 result of an act of rape or incest).”
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This means that insurance plans that provide coverage for abortion would no longer be permitted to sell insurance via the state marketplaces established under Obamacare, which were designed to regulate the standards for basic care.
Graham-Cassidy includes several other provisions that would rollback key features of the ACA, including repealing federal tax credits for healthcare costs and taxes on medical devices, and removing the employer mandate that requires business that employ 50 or more people to offer company-sponsored healthcare plans.
4. The Insurance Industry Is Against It & So Is Jimmy Kimmel
On September 20, insurance giant Blue Cross Blue Shield released the following statement on Graham-Cassidy:
[W]e share the significant concerns of many health care organizations about the proposed Graham-Cassidy bill. The bill contains provisions that would allow states to waive key consumer protections, as well as undermine safeguards for those with pre-existing medical conditions. The legislation reduces funding for many states significantly and would increase uncertainty in the marketplace, making coverage more expensive and jeopardizing Americans’ choice of health plans
The same day, America’s Health Insurance Plans, an influential lobby group that represents a staggering number of insurance providers, penned a letter to Sens. Mitch McConnell and Chuck Schumer:
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, single payer health care to grow.
Dozens of healthcare associations have come out in opposition to Graham-Cassidy, including the AARP, the American Medical Association, and the American Hospital Association, and most of them point to the millions of Americans that would lose health insurance coverage as the reason why.
AARP released a statement entitled “Sounding the Alarm,” claiming their projections found that “the per enrollee cap proposal in Graham-Cassidy-Heller-Johnson will cut between $1.2 trillion and $3.2 trillion from total (federal and state) Medicaid spending over the 20-year period between 2017 and 2036.”
Insurance companies are not the only public voices speaking out against the bill. Talk show host Jimmy Kimmel has been engaged in what many media outlets are calling a “war” against the legislation.
Kimmel has been attacking the healthcare bill on his popular late-night show, calling Senator Cassidy a liar for promising Kimmel back in May that he would only support healthcare plans that ensure those with pre-existing conditions are not denied coverage.
Kimmel had delivered a speech that month about how repealing Obamacare would affect people like his newborn son, who was born with a heart condition that required surgery.
Under the waiver system, states would be able to opt-out of those mandates that protect people with pre-existing conditions, which Kimmel pointed out on his show.
Senator Cassidy responded in a CNN interview saying that Kimmel “does not understand,” to which Kimmel replied the following night: “Oh, I get it, I don’t understand because I’m a talk-show host, right?”
Kimmel added, “Or could it be, Sen. Cassidy, that the problem is that I do understand and you got caught with your G-O-Penis out? Is that possible?”
5. It Only Needs a Simple Majority To Pass
Because Congress is currently making use of a special legislative procedure called budget reconciliation, Graham-Cassidy would only need a simple majority to pass and cannot be filibustered.
Budget reconciliation is an optional procedure designed to force legislation through Congress in order to meet spending considerations outlined in the annual federal budget.
For instance, Congress may change funding to several different budget areas in such a way that conflicts with current laws; a reconciliation bill would include multiple provisions that amend or replace those prior, conflicting laws.
In this case, Republicans have used the opt-in budget reconciliation process all year in an attempt to take advantage of the expedited process and lowered requirements for passage. Previous attempts at ACA repeal this year included the Obamacare Repeal Reconciliation Act of 2017, which failed to pass in July.
Under the terms of budget reconciliation, all legislation must be voted on by September 30, giving Republicans a tight deadline for an already thrice-failed mission.
Graham-Cassidy has the support of President Trump, and Senate maverick John McCain even said he would support the bill given the right circumstances. However, the GOP holds only a two-seat majority in the Senate, and McCain is by no means the only Republican senator who has voted down ACA repeal bills.
Senator Rand Paul (R) already announced that he would not support Graham-Cassidy; McCain and GOP colleagues Sens. Lisa Murkowski and Susan Collins have all expressed serious concerns.
Just two dissenting Republican senators would kill the legislation. If passed, it would move onto the House, where it would also need only a simple majority to become law.