WASHINGTON — The last-ditch Republican effort to repeal the Affordable Care Act is still alive.

The substance of the new proposal is substantially different from the repeal bills that nearly became law earlier this year. Nonetheless, many of the same questions remain.

The bill would deregulate individual insurance markets, slash Medicaid spending, and make it much harder for states to preserve their existing health programs. It could raise costs for Americans with preexisting conditions, limit access to addiction treatment, and reduce spending on public health campaigns, such as childhood vaccinations.

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Just as they did this summer, senators on Sunday circulated last-minute changes aimed solely at bringing reluctant colleagues on board. Once again, the new bill includes more money for Alaska and Maine — where senators have voiced major concerns about the bill — and removes consumer protections that conservatives condemn as inflexible.

Here’s your cheat sheet for the bill, championed by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.), including the latest changes.

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Potential rate hikes for people with preexisting conditions

Graham-Cassidy wouldn’t eliminate Obamacare’s requirement that insurance companies cover people with preexisting conditions, and it wouldn’t let states seek a waiver from that provision, either.

But it would let insurers charge people with preexisting conditions far more than people without them — which is illegal under current law. The new version would also let states raise Obamacare’s cap on out-of-pocket costs. Together, those and other efforts to deregulate the insurance markets could effectively prevent people with expensive health conditions from obtaining coverage, even if it were technically available. Graham-Cassidy would also let states waive some of the law’s essential health benefits — so insurers wouldn’t necessarily be required to cover certain services, such as hospitalization, that might be important to someone with an expensive health condition.

The latest version, moreover, makes it much easier for states to overhaul their insurance markets without federal approval.

More abrupt changes to Medicaid

Like the House and Senate bills before it, Graham-Cassidy shifts Medicaid to a per-capita cap structure, sharply limiting over time how much funding would be available for state policymakers to run those programs.

Many of the changes in Graham-Cassidy would take effect much more quickly than the similar changes included in the Senate’s earlier attempts at health care reform. States that accepted extra federal money to expand their Medicaid programs would see that money disappear in 2020, for example. The bill the Senate rejected earlier this year, in contrast, would have more slowly phased out those dollars beginning in 2021.

The funding formula in Graham-Cassidy, moreover, would ultimately direct more money to states that chose not to expand Medicaid, at the expense of many of those that did — making the policy changes even more significant in the mostly liberal states that have pushed harder to make Obamacare work within their borders.

It’s hard to gauge exactly how deep the Medicaid cuts will be, especially under the new formula in the latest version of the legislation, which won’t be evaluated by the nonpartisan Congressional Budget Office before a vote this week.

Sens. Graham and Cassidy suggest, in their own estimates, the new version will direct more money toward Alaska, Arizona, Kentucky, Maine, and Hawaii — states whose lawmakers have been on the fence about the proposal. Those changes stem from new provisions, including a guarantee that 5 percent of federal funding goes toward rural states and another for states like Alaska with high poverty rates.

Democrats, however, warned that even under the new formula, states will still receive less money than they would have under Obamacare.

No extra funding for addiction treatment

Last time around, Sens. Shelley Moore Capito (R-W.Va.) and Rob Portman (R-Ohio) made a point of extracting as much money as possible for a fund dedicated to addiction treatment and prevention services. Some versions of the legislation ended up including a $45 billion sum over 10 years, an amount that was to be used to fund treatment programs and potentially offset losses for programs funded by the Medicaid spending the bill would have cut. Even the attempted “skinny” repeal bill included a $2 billion, one-year sum.

This time, neither Capito nor Portman has indicated they will push for such a fund in exchange for their support.

Addiction groups and mental health advocates have been steadfast in their opposition to the new bill. They also opposed earlier repeal attempts, including the bill with a $45 billion fund to address the opioid crisis. John Kasich, Ohio’s Republican governor, likened the replacement funding to “spitting in the ocean.”

The bill as currently written includes no funding at all.  

More restrictions for women’s health coverage

Graham-Cassidy effectively defunds Planned Parenthood by prohibiting Medicaid reimbursements to organizations that meet a narrow description almost no other organization fits. The concept of removing the Planned Parenthood provision has been floated as a potential means of winning support from two moderate GOP senators, Lisa Murkowski (Alaska) and Susan Collins (Maine), but any gains in support from that pair could be offset by Republicans in the House unwilling to vote for a bill that does not defund the organization.

The legislation would also put new restrictions on abortion coverage. Right now, in some states, insurers can offer such coverage if they ensure only private money supports that part of the plan. Indeed, states like California and Oregon require the option. Graham-Cassidy would make all of those plans illegal starting next year.

Restrictions on abortion coverage would get broader in 2020, when the legislation’s major changes to federal health care spending would kick in. The new funding structure replaces the current federal contributions to Medicaid, to Obamacare subsidies, and to other programs with lump-sum block grants that state policymakers would allocate however they saw fit. That change would give Republicans new opportunities to put federal restrictions on how states spend those dollars — including a much broader prohibition on any of those dollars going toward abortion coverage.

Reductions in public health spending

The Prevention and Public Health Fund has been easy fodder for Republicans who need to find savings to offset losses from costly bills. It funds almost one-seventh of the money flowing through the Centers for Disease Control and Prevention — a nearly $1 billion sum the bill eliminates entirely. It does leave its $1.25 billion authorization in place in 2018, though various versions of the bill have eliminated the fund a year sooner. The fund fluctuates in value from $1 billion in 2017 to $2 billion after 2025.

If that funding is not eventually replaced, state and local health departments will find themselves on the hook for millions of dollars they currently receive from the federal government for chronic disease prevention, vaccination, and health care integration programs.

More power to the states

In some ways, it’s even harder to predict how the Graham-Cassidy legislation could affect individual Americans than it was to forecast the impact of previous attempts. The new bill leaves nearly all major decisions about how to run Medicaid and individual insurance markets to state governments, all while hugely cutting the federal government’s contributions to those programs.

In May, back when Cassidy’s repeal attempt was an afterthought, he was resolute in his belief that health care professionals — he’s a kidney doctor — have an innately better grasp on health policy than others.

He asked STAT: “How could it be otherwise?”

But dozens of public health, disease, and patient advocacy groups — even insurance companies — have formed a rare alliance to issue public statements opposing the legislation. No major health group has endorsed it.

“You know, I could maybe give you 10 reasons why this bill shouldn’t be considered,” Sen. Chuck Grassley (R-Iowa) told reporters in his state last week. “But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”

Republican leaders are hoping for a vote as early as Wednesday, before the Sept. 30 deadline to pass the bill with a simple majority.

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  • Put aside that the reasoning of “the bill should be passed because we promised it regardless of the substance” is the epitomy of poor decision making and my ten year old explains why that is,so eloquently.
    Also I have been a nurse for 24 years, most of that time in Emergency Depts. for the last ten years in Urgent Care. I can assure you when someone has a life changing diagnosis, of which I can name hundreds, do they say well thank god I saw that coming and had chosen the benefits to cover it Mr Graham could come up with a few from his own career in Medicine. Also I have not heard or seen any comments on how Emergency Depts will be affected. I know in my community emergency depts are overloaded and often times there is a back log of patients (15-20) just waiting for a room to open. Often the hospital is full with no rooms available who is responsible for the care of these patients? The nurse in the ED. Think if this was your job…
    I would love a response zero my questions and am eagerly wAiting for that response

  • Hi, There was no cheat sheet. Would you please be so kind as to send me the link or the sheet. Thanks, Stephen
    Here’s your cheat sheet for the bill, championed by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.), including the latest changes.

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