Speaking at the United Nations, President Trump said the Cassidy-Graham health-care bill was likely to pass on Sept. 20. (The Washington Post)

THE MORNING PLUM:

Senate Republicans are stumbling forward with their new zombie Trumpcare bill to repeal Obamacare — and they will hold a vote this month, before the nonpartisan Congressional Budget Office tells them how many people might be tossed off of coverage if it becomes law. The drawback of this — or is it a benefit, given that the public is also being kept in the dark? — is that Republicans will vote on the bill without knowing all that much about how it would impact their own states, not to mention the rest of the country.

Unfortunately for the bill’s supporters, a new study just came out that will enable Republicans to make a somewhat more informed decision about this legislation, after all. And it could deal a blow to the bill’s chances. It should, anyway.

The study, which was released this morning by Avalere Health, a consulting firm, finds that many states will see sizable cuts to the federal money that would flow to their states, relative to current law. Some of those states are represented by the GOP senators who are currently deciding whether to back the bill, including Lisa Murkowski (Alaska), Susan Collins (Maine), Rob Portman (Ohio) and John McCain (Ariz.).

Here’s a chart from the study that demonstrates how the bill — which is being championed by Sens. Bill Cassidy (R-La.) and Lindsey O. Graham (R-S.C.) — would impact the federal funding to states. Because of the bill’s complex funding formula, some states gain, relative to what spending would be under current law (the Affordable Care Act), and others lose. The blue ones are the losers. (Click on the chart to enlarge it.)


Graham-Cassidy kills the ACA’s Medicaid expansion and subsidies for lower-income enrollees on the exchanges, starting in 2020, and replaces them with block grants to the states, which can then spend the money on coverage in other ways, or on other things entirely. (After 2026, the block grants end.) The bill’s proponents claim that the states will merely gain flexibility under it.

But as the new study shows, because of the bill’s funding formula, a lot of states will end up with substantially less federal money to spend on health-care coverage than they would have under current law. In the period from 2020 to 2026, overall the bill will mean a $215 billion cut to federal spending. Here’s how that cut will impact individual states:

  • Arizona would get $11 billion less. McCain, who was one of the three senators who sank “skinny repeal,” has said he may oppose the bill because he is unhappy with the lack of regular order, but on top of that, we now learn his state would take a hit, too.
  • Alaska would get $1 billion less. Murkowski has emerged as a key swing vote — she also helped sink “skinny repeal” and has opposed deep Medicaid cuts. She has said she wants to learn more about how the new bill would impact her state. Now she knows. “Alaska might seem like a big state geographically, but it’s actually a small state in terms of health spending, so a $1 billion reduction is a massive cut,” Topher Spiro, a health policy analyst at the Center for American Progress, told me today.
  • Ohio would get $9 billion less. Portman is in a weird spot, because Ohio Gov. John Kasich has been scaldingly critical of the bill, and now it looks as though it would really wallop his state.
  • Maine would get $1 billion less. Collins, who also helped sink skinny repeal, is said to be leaning against Graham-Cassidy, and now this should help cement her opposition. Spiro adds that Maine is also a state with low health spending, making this a big cut.
  • West Virginia would get $1 billion less. Sen. Shelley Moore Capito (R-W.Va.) has repeatedly criticized in sharp moral terms the damage that the previous repeal bill’s deep Medicaid cuts would inflict on her constituents.

Rand Paul, who is thought to be a hard “no,” has previously criticized the bill for redistributing money among states. This study illustrates in graphic new detail just how bad this would be. As Elizabeth Carpenter, a senior vice president at Avalere, put it:

“The largest impact of the proposed bill would be the reallocation of federal dollars between states. Medicaid expansion states and states that have enrolled a high number of people in insurance affordability programs would be most adversely impacted.”

And a lot of Republican senators represent such states. Colorado (Cory Gardner) would lose $6 billion. Pennsylvania (Pat Toomey) would also lose $6 billion. Florida (Marco Rubio) would lose $4 billion.

Here’s another key point: The cuts get substantially worse after 2026, when the block grants run out. According to the Avalere study, if you factor in the total cuts under Graham-Cassidy from 2020 to 2036 — including 10 years after the block grants expire — that means a $14 billion cut to Alaska; a $133 billion cut to Arizona; a $161 billion cut to Ohio; a $17 billion cut to Maine; and a $27 billion cut to West Virginia.

In other words, the bill also creates a massive fiscal cliff for many states who stand to take an enormous wallop after 2026. The bill’s proponents say Congress will reauthorize the spending at that point. But states cannot count on that, and they will have to plan accordingly, making it extremely challenging to design programs, even with additional “flexibility.” The bottom line: GOP senators who vote for Graham-Cassidy will be voting not just to slash funding to their own states in the short term; but also possibly to put them in a seriously damaging long term bind.

Senate Republicans are trying to revive the momentum to overhaul the Affordable Care Act with the Cassidy-Graham proposal. Here are five things to know about the plan and the rush to pass it. (Jenny Starrs/The Washington Post)

* RNC SHELLS OUT BIGLY FOR TRUMP’S LEGAL FEES: CNN reports that the Republican National committee coughed up more than $230,000 in August to cover Trump’s legal fees in the ongoing Russia probe:

The RNC paid Trump’s personal attorneys Jay Sekulow and John Dowd $131,250 and $100,000, respectively, via their law firms, the official said. … The RNC has also begun to foot the legal payments of Trump’s son, Donald Trump Jr. The committee paid nearly $200,000 of Trump Jr.’s legal bills related to the Russia investigation…

Hey, if it results in a nice, fat tax cut for big GOP donors, it will all have been worthwhile.

* MOUNTING OPPOSITION TO GRAHAM-CASSIDY: The New York Times takes stock of the depth of opposition, particularly on one lone senator from Alaska:

It was the opposition of Alaska’s governor, Bill Walker, that might prove most important. He increased pressure on Senator Lisa Murkowski, Republican of Alaska, to cast what could be a deciding vote to kill the repeal effort. … The American Medical Association, the American Hospital Association and AARP, the lobby for older Americans, all urged the Senate to reject the bill. And 10 of the 12 governors opposing the measure signed a letter urging Senate leaders to scrap it.

On the other side is Trump, who desperately wants to sign something that in his mind constitutes wiping his feet on former president Barack Obama’s face, and Senate Majority Leader Mitch McConnell (R-Ky.), who hopes to avoid Trump’s Twitter wrath. Easy call, Sen. Murkowski!

* WHY IS MURKOWSKI STILL UNDECIDED? The Post explains that Graham-Cassidy could be even worse for Mukowski’s home state of Alaska than previous ones (which she opposed) were:

Certain aspects of the new bill pose an even bigger challenge for Alaska than previous proposals did. Health-care premiums are particularly expensive in the state, given its many remote areas. … Since federal tax credits over time would be equalized and based on the number of low-income people in a given state, that new calculation would eliminate the more generous subsidies Alaska enjoys.

And on top of that, Graham-Cassidy’s Medicaid cuts would also hit Alaska, which expanded Medicaid.

* GOP LAWMAKERS ‘PUZZLED’ ABOUT GRAHAM-CASSIDY: Politico offers an eyebrow-raising tidbit:

GOP lawmakers … are eager to fulfill their seven-year repeal vow but … remain puzzled about what the bill would actually mean for their home states — especially since the Congressional Budget Office said it will not have details about the practical implications of the bill, including how many people could lose coverage and the impact on insurance premiums, “for at least several weeks.”

Huh. You’d think they might want to figure out what the bill means for their states before voting on it. Yet at least 45 GOP senators, and probably more, will vote yes without knowing this.

* OBAMACARE SABOTAGE WORKS: Trump’s Department of Health and Human Services has slashed the budget for advertising to try to boost enrollment on the ACA exchanges. But HuffPost’s Jonathan Cohn reports that internal HHS data show that the ads worked in the past:

The HHS research suggested that, combined, all advertising was responsible for about 37 percent of new enrollees signing up. … In addition, HHS found, advertising had driven a roughly equal proportion of existing enrollees to shop on healthcare.gov and re-enroll that way. The last part is important, because enrollees who shop around for new plans rather than simply enrolling in the same ones can frequently find better deals.

No wonder they cut the budget on the enrollment ads. Can’t have Obamacare succeeding, can we?

* MUELLER IS REACHING DEEP INTO PAUL MANAFORT’S DEALINGS: CNN scoops that special counsel Robert S. Mueller III’s probe is reaching back more than a decade in examining former Trump campaign chair Paul Manafort’s business dealings:

The broad time frame is the latest indication that Mueller’s team is going well beyond Russian meddling during the campaign as part of its investigation of Trump campaign associates. … Mueller’s team has warned Manafort that they are working to charge him with possible tax and financial crimes, the sources said, an indication the investigation could be in an advanced stage.

Bonus tidbit: Mueller has the notes that Manafort took at the meeting set up by Donald Trump Jr. which signaled the Trump team’s eagerness to collude with Russian efforts to tip the election.

* AND JIMMY KIMMEL WEIGHS IN AGAIN: Sen. Bill Cassidy (R-La.) previously endorsed the “Jimmy Kimmel test,” based on Kimmel’s suggestion that no child should lack care because a family can’t afford it. Last night, Kimmel ripped into Cassidy for failing the test with the Graham-Cassidy bill:

“Not only did Bill Cassidy fail the Jimmy Kimmel test, he failed the Bill Cassidy test. … This guy, Bill Cassidy, just lied right to my face … We can’t let him do this to our children and our senior citizens and our veterans or to any of us. … I am politicizing my son’s health problems — because I have to. … There’s a new Jimmy Kimmel test for you. It’s called the lie-detector test. You’re welcome to stop by the studio and take it anytime.”

Something tells us that Cassidy might not take Kimmel up on that.