Politico reports that Sen. Lisa Murkowski (R-Alaska), the key swing vote, is having intense discussions with Health and Human Services Department bureaucrats about what the bill — which is sponsored by Sens. Lindsey O. Graham (R-S.C.) and Bill Cassidy (R-La.) — would really do. Thus, swing senators are still trying to figure out what impact it would have on their states.
But the whole bill could still change — in a big way. In addition to killing the mandate and the Medicaid expansion and subsidies and replacing them with block grants to states that will mean less money for many of them, Cassidy-Graham also allows states to seek waivers from the ACA’s provisions that prevent insurers from gouging people with preexisting conditions and require them to cover essential health benefits.
This is meant to give states “flexibility,” in part to use federal funds to cover people as they see fit, and in part to let insurers offer skimpier coverage and/or lower prices for healthy people. It’s also why the bill would effectively weaken or kill protections for people with preexisting conditions — while insurers cannot explicitly deny those people coverage, they can jack up their premiums and decline to offer benefits they need, leaving them stranded.
But some health policy analysts think there’s a decent chance that the parliamentarian will strike those deregulatory features under the Byrd Rule, because they don’t have a direct budgetary component. Daniel Hemel of the University of Chicago, for instance, points out that a very similar feature was struck from a previous GOP repeal bill and thinks it should — and very well may — happen again.
We don’t know whether this will happen. But it’s possible, and if so, it would be a big deal. Senators would then be voting on a bill that leaves the ACA’s regulations on preexisting conditions and essential health benefits in place but gives the states less money to cover people. I asked Hemel what the consequences of this would be, and he emailed:
Without the waiver provision, Graham-Cassidy is a totally different bill. It doesn’t provide states with flexibility, but it still takes away a lot of money. This would change the terms of the debate entirely — and would do so just a few days before the senators cast their final votes.
Hemel added that “the most likely scenario” is that the parliamentarian determines “that the provision is primarily non-budgetary and so must be stricken from the bill.” Nicholas Bagley of the University of Michigan agrees and adds that this would mean that a primary selling point for the bill would vanish: It would no longer meaningfully offer the states “flexibility” and would no longer constitute the “federalism” that supporters have extolled.
An additional point: The “flexibility” argument is also an inducement to get states that have expanded Medicaid to accept an outcome in which block grants replace the Medicaid expansion. This is the core of the conservative argument for Cassidy-Graham — many states get less money, but more flexibility to define down what counts as coverage — and it’s one that undecided senators are weighing. Murkowski has said she is trying to decide whether this flexibility makes the trade-off worth it. But if the parliamentarian strikes the waiver provisions, Cassidy-Graham would only be offering the block grants — which mean a reduction in funding — without the flexibility that is meant to sweeten that deal and give states leeway to make that funding work for them.
It’s hard to see how Murkowski — and perhaps other GOP senators from Medicaid expansion states — could accept such an outcome. At that point, they’d only be voting to gut the government’s commitment to trying to expand coverage to all their constituents, including the poorest of them — without even the “flexibility” argument to give them cover for it.
What’s more, if that ruling were to happen, it would dramatically change Cassidy-Graham with very little time left before the vote to figure out what the consequences would be. If you think this process has been a disaster so far, it could get a whole lot worse.
* MUELLER SCRUTINIZES TRUMP’S EXPLANATION FOR KEY MEETING: The New York Times reports that Robert S. Mueller III is scrutinizing President Trump’s role in falsifying the reason for the meeting between top Trump campaign officials and the Russian lawyer:
In July, when The Times put questions about the meeting to the White House, Mr. Trump and senior administration officials prepared a response on Air Force One that made no mention of the meeting’s real purpose, saying instead that it focused on Russian adoptions. Mr. Mueller has asked for all documents the White House has about the meeting, and all internal White House communications about the statement drafted on Air Force One.
We subsequently learned from Donald Trump Jr.’s email chain that Trump officials eagerly took the meeting in the expectation of dirt about Hillary Clinton provided by the Russian government.
* MUELLER DEMANDS DOCUMENTS RELATING TO COMEY FIRING: The Post adds the nugget that Mueller wants all documents relating to Trump’s firing of former FBI director James B. Comey:
Mueller has asked for all documents related to meetings between Trump and Comey while Comey served at the FBI, records of any discussions regarding Comey’s firing and any documents related to a statement by then-press secretary Sean Spicer made on the night Comey was fired. He has also asked for any documents related to a meeting Trump held in the Oval Office with Russian Foreign Minister Sergei Lavrov the day after Comey was fired.
Our picture of the process behind the Comey firing is based on dogged reporting and Comey’s testimony, and remains incomplete — but could be at the core of Trump’s possible obstruction of justice.
* A PAUL MANAFORT TIMELINE: The Post reports that former Trump campaign chair Paul Manafort offered a Kremlin-allied billionaire a private briefing on the campaign. Axios offers up a comprehensive timeline of much of what is known about Manafort, and how it emerged. The summary:
Manafort was in the room when Donald Trump Jr. met with a Russian lawyer hoping for dirt on Hilary Clinton. One month later, he reportedly sent an email to a Russian billionaire offering private briefings on the campaign. Before he even signed on with Trump, the FBI was reportedly secretly monitoring his calls. Now, he’s at the center of Robert Mueller’s investigation.
The full timeline paints a picture of a probe that is slowly closing in.
* NOBODY KNOWS WHETHER CASSIDY-GRAHAM CAN PASS: Politico recaps the state of play, noting that there will likely be a vote next week, but it’s unclear whether it can get 50 senators. And this:
It’s still anyone’s guess whether the bill’s backers can get to 50 votes. One Republican senator suggested that [Senate Majority Leader Mitch] McConnell may ultimately decide to bring the bill up for another failed vote, in part to show GOP donors and President Donald Trump that the Senate GOP tried again.
If it fails, surely Trump will rationally evaluate the outcome, conclude repeal just doesn’t have enough support, and refrain from furiously spraying tweets at McConnell ever again.
* ALASKA HEALTH CARE COULD BE DEVASTATED BY GRAHAM-CASSIDY: With Sen. Lisa Murkowski still undecided on Cassidy-Graham, Becky Hultberg, president of the Alaska State Hospital and Nursing Home Association, sounds the alarm:
“The cuts could be devastating to our health care system, including rural and frontier hospitals that operate on razor-thin margins,” Ms. Hultberg said in an interview. “These hospitals are often accessible only by airplane or ferry, so the loss of a hospital means an expensive and disruptive medical evacuation out of the community.”
It would also mean substantially less money for her state. It’s still unclear why this is even a hard call for Murkowski, who already voted against previous repeal bills that weren’t this bad.
* TRUMP’S APPROVAL TICKS UP — BUT DID OUTREACH TO DEMOCRATS HELP? NBC’s First Read crew brings us a new NBC-Wall Street Journal poll finding that Trump’s approval has inched up to 43 percent. But this could be “with the help of his bipartisan move”:
71 percent of Americans support his deal with Democrats Chuck Schumer and Nancy Pelosi on hurricane relief and keeping the government open for three months. The bad news: The public gives Trump low marks on almost everything else.
The new NBC poll finds Trump’s numbers on numerous specific issues to be in the toilet. No doubt Trump will learn from this by scotching any outreach to Democrats while pressing forward with everything else.
* MORE ABSURD GOP DISSEMBLING: After Jimmy Kimmel unloaded on him, Sen. Bill Cassidy insisted that “more people will have coverage” under his bill. Glenn Kessler debunks the claim by pointing out that deep cuts to spending will likely mean less coverage.
As one expert notes: “It’s a very high bar to argue that federal funding to states will be cut by $160 billion (other estimates are higher) between 2020 and 2026 (forget whether it ends in 2027 or not) and coverage will stay the same or increase.” This is just another version of the same old claim that magical GOP solutions will — presto! — mean more coverage for less money.
* HOPES THAT TRUMP WILL EVOLVE ARE DELUSIONAL: E.J. Dionne Jr. looks at all the problems with Trump’s speech to the United Nations and makes an important point about some commentators who bent over backward to praise it:
He also won praise from a group who are not really Trump-friendly but whom I have come to see as inspired by a hope: They calculate that if enough people say enough encouraging things whenever Trump seems to offer relatively normal ideas or take normal actions, he will respond to positive reinforcement and do more normal things over time. Perhaps this would prove to be true, but it sounds like a coping technique that parents of teenagers might employ, and that is disturbing.
What’s also odd is that each time we see this sort of response, Trump promptly does something crazy or disgusting that proves how delusional it is. Yet it keeps coming back.