The Washington PostDemocracy Dies in Darkness

Opinion Cassidy-Graham and fuzzy math

Sen. Bill Cassidy (R-La.) arrives for a meeting about the Republican health-care bill on Capitol Hill in Washington on July 19. (Aaron P. Bernstein/Reuters)

The Post reports on the latest in the saga of the Graham-Cassidy health-care bill:

Powerful health-care groups continued to rail against the bill, including AARP and the American Hospital Association, both of which urged a no vote. But it was unclear whether the opposition would ultimately derail the attempt, as key Republican senators including Lisa Murkowski of Alaska said they had yet to make up their minds.
The measure marks the last gasp of Republican attempts to dramatically gut Obama’s Affordable Care Act, which has added millions of people to the ranks of the insured through a combination of federally subsidized marketplaces and state-level expansions of Medicaid, leading to record lows in the number of those without health insurance. The Graham-Cassidy bill — named for Sens. Lindsey O. Graham (S.C.) and Bill Cassidy (La.) — would convert funding for the ACA into block grants for the states and would cut Medicaid dramatically over time.

What is striking is the degree of haphazardness and lack of specificity that infuses the entire process. Experts on different sides come up with wildly different numbers, which differ from one another — all derived in good faith — and from the Graham-Cassidy numbers, which seems to lack the analytical rigor one would expect of something so serious. The implications of the bill are obscured by carefully scripted talking points. Yes, the bill leaves in place the ACA’s provision requiring insurers to offer coverage for preexisting conditions. But wait — states can easily obtain waivers charge more for certain services. Oh, governors wouldn’t want to do that to their people! Really? Preexisting exclusions were quite common before Obamacare put an end to them. Moreover, some analyses do not calculate the impact of a per capita cap on the Medicaid program; that’s a hard calculation, I am told. For all of these reasons, it is especially important to have a complete Congressional Budget Office scoring — something the bill’s sponsors will not have in hand before the vote, if it comes, next week.

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)

Of most concern should be the impact on Medicaid. The Kaiser Family Foundation finds:

Much is at stake for low-income Americans and states in the Graham-Cassidy proposal. The recent debate over the [American Health Care Act] and the [Better Care Reconciliation Act] has shown the difficulty of making major changes that affect coverage for over 70 million Americans and reduce federal funding for Medicaid. Medicaid has broad support and majorities across political parties say Medicaid is working well. More than half of the states have a strong stake in continuing the ACA Medicaid expansion as it has provided coverage to millions of low-income residents, reduced the uninsured and produced net fiscal benefits to states. Graham-Cassidy prohibits states from using Medicaid to provide coverage to childless adults. With regard to Medicaid financing changes, caps on federal funding could shift costs to states and result in less fiscal flexibility for states. States with challenging demographics (like an aging population), high health care needs (like those hardest hit by the opioid epidemic), high cost markets or states that operate efficient programs may have the hardest time responding to federal caps on Medicaid spending. Faced with substantially reduced federal funding, states would face difficult choices: raise revenue, reduce spending in other areas, or cut Medicaid provider payments, optional benefits, and/or optional coverage groups.

Manatt Health finds:

Over 2020 to 2026, the block grant would provide states with $81.6 billion less in federal funding than would be available under current law, a reduction of 6.4 percent. In 2026, national funding for the block grant is 8.9 percent below current law spending projections.
Most states would receive less funding under the block grant than under current law. … 32 states would receive less federal funding in 2020 under the unadjusted amount of the block grant. By 2026, some states fare better, but the majority (27 states) continue to face a loss of federal funding. Over the 2020 to 2026 period, 29 states receive less in federal funding with an average reduction of 19 percent.
In some states, the loss of federal funding is significantly higher, reflecting the disparate impact of the Graham-Cassidy proposal on states that have expanded Medicaid and/or generally have higher-cost care. States such as Alaska, Connecticut, Delaware, New Hampshire, New Mexico, New York, Oregon, Vermont, and Washington would see reductions of 25 percent or more over the 2020 to 2026 period under the Graham-Cassidy unadjusted allotments relative to current law.

More than with any previous health-care proposal, the level of complexity coupled with the level of uncertainty here make proceeding without full hearings and scoring particularly reprehensible.