Republican Senators have proposed one more bill to repeal the ACA. The Graham-Cassidy (or Cassidy-Graham) proposal would dramatically shrink the pool of federal money going to healthcare and revise how it’s distributed to states, in a way that is especially damaging to states that accepted the ACA’s Medicaid expansion. They hope to pass this destructive bill before the end of September, due to the upcoming expiration of reconciliation rules that let them pass a healthcare-related bill with votes from 50 Senators and Vice President Mike Pence.
Like Republican bills from earlier in the year, Graham-Cassidy would cap Medicaid spending, which would lead to fewer people having Medicaid coverage and reductions in benefits. It would go even farther than previous bills in ending the ACA’s Medicaid expansion, terminating it completely in 2020. It also keeps earlier bills’ one-year prohibition on reimbursing Planned Parenthood for services it provides Medicaid enrollees, an action that disproportionately harms low-income women. Edwin Park and Matt Broaddus of the Center on Budget and Policy priorities estimate that in 2027 alone, the bill would result in nearly $300 billion less in federal funding relative to current law. This bill wouldn’t just take us back to the bad old days before the ACA; it would fundamentally alter the Medicaid program that has allowed so many millions of children, pregnant women, people with disabilities, and low-income seniors access to care they otherwise couldn’t afford.
In the individual market, Graham-Cassidy ends the federal subsidies designed to make insurance affordable for people with incomes under 400% of the poverty level and repeals the individual mandate. It also allows states to rescind the ACA’s prohibition on charging more to enrollees with pre-existing conditions, and to stop requiring plans to include essential health benefits (including prescription drugs and maternity care). Individual insurance policies may still be for sale, but they’ll be completely out of reach for many — not only because subsidies have disappeared and premiums can increase based on an enrollee’s health history, but because scrapping the individual mandate will mean smaller risk pools, which translates to less stability for insurers.
At the same time, the Trump administration’s unwillingness to commit to making necessary payments to insurers has already contributed to higher premiums, and its decisions to slash important advertising and outreach programs are expected to substantially reduce enrollments for 2018. The Trump administration has already harmed the individual market for insurance. Graham-Cassidy will make the situation much worse for all but the youngest, healthiest enrollees — and even they could see their premiums soar if they develop expensive health conditions.
In answer to criticisms about millions of people losing coverage, the bill’s backers point to a pot of federal money that will be divided amongst states. States that expanded Medicaid will see their federal funds plummet, while those that didn’t will get relatively more money — but still far too little to actually solve the uninsurance problem that the ACA did so much to address. And the states wouldn't be required to direct the funds toward increasing coverage for low-income populations.
This is the important thing to keep in mind as Republican Senators push this bill with claims about Obamacare being broken: The ACA wasn’t perfect, but it substantially reduced this country’s shameful rate of uninsurance. Approximately 20 million people gained insurance between 2010 and early 2016, and the newest number from the Census Bureau show that uninsurance continued to decline. Problems with affordability of premiums and deductibles remained, but the majority of people with new ACA marketplace or Medicaid plans were satisfied.
At the moment, Senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) are working on legislation to stabilize the ACA, instead of creating a situation that’s far worse than what we had prior to 2010. They've held hearings and delved into details about insurance markets. This is a much more responsible approach than eviscerating Medicaid and destabilizing the individual market.
Another thing to monitor is whether Senate Republicans wait for a Congressional Budget Office score before rushing to vote on a bill that imperils millions of people’s access to health insurance. CBO scores of Republican proposals earlier this year have calculated that they’d cause more than 20 million people to lose coverage over the next decade. (Specifically, by 2026 the American Health Care Act would have led to 23 million more uninsured and the Better Care Reconciliation Act to 22 million fewer with coverage.) Graham-Cassidy is somewhere between those proposals and an ACA repeal bill that was passed by a Republican Congress and vetoed by President Obama, which CBO calculated would lead to 32 million more uninsured by 2026 relative to current law.
Failing to wait for a CBO score before holding a vote is irresponsible in the extreme — but, alas, something we’ve seen already from this Congress. With or without a CBO score, a vote on Graham-Cassidy is very likely to happen in the next two weeks. That doesn’t leave much time for Senators to hear from their constituents what they think about a bill that will affect so many millions of people.
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