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Opinion The new version of Cassidy-Graham may be crueler and more cynical than the last

Health-care protesters and disability advocates gathered on Capitol Hill on Sept. 25 and lined up to attend the hearing for the GOP's Cassidy-Graham plan. (Video: The Washington Post, Photo: Manuel Balce Ceneta/The Washington Post)


Sens. Bill Cassidy (R-La.) and Lindsey O. Graham (R-S.C.) are rolling out a new version of their repeal bill on Monday, and the changes to it are unabashedly clear in their intentions: They are designed to win over the few Republican senators who continue to say they may oppose the bill. But in so doing, Cassidy and Graham have revealed one of the core reasons the bill is in such deep trouble: Each time they lurch in one direction to appease one holdout, they risk driving another holdout away.

The new version is designed to win over a key moderate Republican senator who remains undecided, Sen. Lisa Murkowski, by nominally throwing more money at her home state of Alaska. Yet at the same time, it also appears to try to win conservative holdouts with new language that some experts say would further weaken protections for people with preexisting conditions.

Murkowski is on record with repeated statements opposing any such weakening of protections. And so, if these experts are right, and if Murkowski’s previous pronouncements mean anything at all, there is simply no principled way she can possibly allow this new money to buy off her vote.

Senate Republicans are trying to revive the momentum to overhaul the Affordable Care Act with the Cassidy-Graham proposal. Here's a breakdown of the bill. (Video: Jenny Starrs/The Washington Post, Photo: Melina Mara/The Washington Post)

The new version of the bill is similar to the old one in that it still ends the Affordable Care Act’s Medicaid expansion and subsidies and replaces them with block grants to states, which would result in substantially less money for many states over time. But as Dylan Scott explains in a useful rundown of the changes, the new one uses various new funding mechanisms that appear mainly designed to steer more money back to Alaska.

At the same time, however, the new version appears to go further in weakening protections for sick people, apparently to win over conservatives who continue to express reservations, such as Sens. Rand Paul (R-Ky.), Ted Cruz (R-Tex.) and Mike Lee (R-Utah). It would apparently do this by allowing states to waive the prohibition on insurers jacking up rates for people with preexisting conditions — without even seeking a waiver from the federal government. Under the previous version such a waiver would be required. Under the new one, states merely have to file notice of their plan. Here’s how Larry Levitt of the Kaiser Family Foundation summarized those particular changes:

The revised Graham-Cassidy bill is in effect federal deregulation of the insurance market. States no longer have to submit waivers of insurance rules under the revised Graham-Cassidy bill. They just have to describe their plans. … If there was any question about Graham-Cassidy’s removal of federal protections for preexisting conditions, this new draft is quite clear.

Nicholas Bagley, a health policy expert at the University of Michigan, tells me he thinks the new version of the bill is not quite that clear-cut: There is some language in it, he notes, that contradicts itself on this point. But he says a reasonable reading of the new text suggests it does weaken these protections. “Although the bill is convoluted and to some extent internally inconsistent, it suggests that states can allow their insurers to vary their premiums based on anything other than sex or genetic status, including on the basis of health status,” Bagley emails me.

Murkowski has repeatedly said she is trying to determine whether the added flexibility Cassidy-Graham gives to her state is worth the trade-off of losing funding, meaning that if her state doesn’t lose money, she might be able to support it. But that is not all Murkowski has said. On other occasions, she has explicitly and forcefully said that the ACA’s protections for people with preexisting conditions must remain in place — everywhere. Here’s how she put it in a speech to the Alaska state legislature in February:

“I am insisting that there are elements of the ACA that must be saved, that must be preserved. For example, we must continue to prohibit insurers from discriminating against preexisting conditions. … as long as this Legislature wants to keep the [Medicaid] expansion, Alaska should have the option – so I will not vote to repeal it.”

And here’s how Murkowski put it in a letter to constituents in June:

“I am committed to ensuring that important provisions of the ACA, such as covering those with preexisting conditions, continued support for Medicaid expansion, coverage for dependents and no lifetime limits, and funding for Planned Parenthood remain intact.”

In both these cases, Murkowski clearly stated that the protections for people with preexisting conditions must be preserved as they currently exist in the Affordable Care Act. While Cassidy-Graham does not allow states to permit insurers to explicitly deny insurance on that basis, the bill in effect guts these protections, by allowing states to let insurers jack up premiums on those people, pricing them out of the market. The new version appears to make this even easier, and subjects such efforts to less federal oversight than the last.

This is something Murkowski has plainly opposed. Is the new money for Alaska really mitigating? It shouldn’t be on the face of it. But it gets worse: As Jonathan Cohn notes, it’s not even clear, absent more rigorous analysis, whether the new money for Alaska will amount to what is advertised — a peril of this absurdly rushed process. What’s more, as other liberal wonks point out, the long-term cuts that would decimate Medicaid coverage everywhere remain even in the new version.

The bill’s proponents appear to be making a last-ditch cynical play that works like this: If Murkowski secretly wants to vote for repeal, the added money will allow her to do so while claiming she is prioritizing the interests of her state, and hopefully there will be enough confusion around the gutting of protections for preexisting conditions to allow her to finesse the politics on that front. But then Murkowski would be confirming that added money to her state — which, again, is uncertain in its real effects and won’t mitigate the bill’s deep long-term cuts — was sufficient to get her to toss aside her own stated principles. Indeed, if anything, these overall changes should make it harder for her to support the bill, not easier — if her previous public statements were rooted in anything approximating principles to begin with.

* CASSIDY-GRAHAM’S NUMBERS ARE IN THE TOILET: A new CBS News poll finds that only 20 percent of Americans, and only 46 percent of Republicans, approve of Cassidy-Graham. Note this:

Most people want the Affordable Care Act to be improved, not repealed. Three in four said the law should either be kept in place (9 percent) or that it has some good things in it but needs some changes (65 percent). One in four said it has so much wrong with it that it should be repealed and replaced entirely. Nearly half of Republicans were of this view, indicating partisan divisions still run deep on this issue. However, about as many Republicans said there were some good things in the law and only changes are needed.

The GOP repeal bills have been so abysmally awful that even Republican voters are giving Obamacare another look.

* COLLINS LEANS HARD AGAINST CASSIDY-GRAHAM: Sen. Susan Collins (R-Maine), on CNN’s “State of the Union,” all but declared that she will vote against Cassidy-Graham:

“It’s very difficult for me to envision a scenario where I would end up voting for this bill. … I’m concerned about the impact on the Medicaid program, which has been on the books for more than 50 years and provides health care to our most vulnerable citizens … I’m very concerned about the erosion of protections for people with preexisting conditions, like asthma, arthritis, cancer, diabetes.”

It’s useful having a Republican confirming that the bill would, in fact, gut protections for people with preexisting conditions, since its proponents are lying endlessly on this point.

* NEW AD HAMMERS REPUBLICANS ON CASSIDY-GRAHAM: The advocacy group Protect Our Care is out with a new ad in D.C. that reminds returning GOP senators just how widespread the opposition to Cassidy-Graham really is. As the ad puts it: “Every health care group you trust, like the American Medical Association, AARP, the American Cancer Society, and dozens of others strongly oppose the bill.”

Has there been any other major piece of legislation in recent memory that has met with such widespread and vehement opposition from experts, stakeholders and the public alike?

* TRUMP’S TRAVEL BAN EXPANDS: You probably never saw this coming, but the White House has announced that the travel ban will be continued for the foreseeable future, with Chad, North Korea and Venezuela added to the list. And:

“The restrictions either previously or now were never, ever ever based on race, religion or creed,’’ one senior administration official said. “Those governments are simply not compliant with our basic security requirements.”

Never? What about all of those times that President Trump promised to ban “Muslims”? The ban will be argued over at the Supreme Court on Oct. 10.

* TRUMP PREDICTS AN EVENTUAL ‘WIN’ ON HEALTH CARE: Here’s Trump, telling reporters yesterday that “eventually” Trump and Republicans will “win” on repeal:

“I don’t know what they’re doing, but you know what? Eventually we’ll win, whether it’s now or later.”

Trump will also eventually get that wall. By the way, it matters that Trump only views repeal as a “win,” with zero concern for what’s in any repeal bill or its consequences for millions.

* DEMOCRAT LEADS IN VIRGINIA GUBERNATORIAL RACE: A new Wason Center poll finds Democrat Ralph Northam leading Republican Ed Gillespie, 47 percent to 41 percent, among likely voters in Virginia, with just over a month left to go. The polling averages put Northam up by just under four points.

This is a major test of the political environment in the Trump era and would underscore that Democrats hold the advantage heading into the 2018 elections. Also recall that many of the big races next year are gubernatorial contests, and Democrats badly need to make up ground in the states.


Since the Republicans launched this year’s repeal offensive, many Americans who thought of the Affordable Care Act as a vague sort of failure have heard the compelling stories of those with preexisting conditions and serious illnesses who are far better off today because of the law. … Many who believed Trump and other Republicans when they promised to pass something better than Obamacare now know that this pledge was a sham. What the GOP really wants is to spend a lot less government money helping people get health care. But Republicans can’t admit this because it sounds heartless.

The question is whether a large enough handful of Republicans has come to reject this position and is willing to accept the reality of the ACA’s successes.

* REPUBLICANS ARE LYING ABOUT THEIR TAX CUTS: Paul Krugman notes that Republicans are already trying to sell their eventual tax cuts for the rich by invoking the spectacular economic growth it will supposedly unleash:

At this point, however, few people believe them. The Bush tax cuts didn’t create a boom; neither did the Kansas tax-cut “experiment.” Conversely, the U.S. economy did fine after the 2013 Obama tax hike, as has the California economy since Jerry Brown raised state taxes. Party apparatchiks will no doubt engage in an orgy of Reaganolatry, but the broader public probably won’t be moved by (false) claims about the wondrous results of tax cuts 36 years ago.

Also note that Trump is now saying he always cared a lot more about winning on tax “reform” than on repeal. If there’s one thing Republicans probably will win on, it’s tax cuts of some kind.