with Paulina Firozi


If you're a conservative Republican who believes in empowering states instead of the federal government, voting for the latest Obamacare overhaul bill absolutely makes sense. But if you're a moderate Republican who has fretted all along about cutting health-care benefits, it absolutely doesn't.

Just like the health-care bill the Senate rejected in July, the plan that GOP Sens. Bill Cassidy (La.) and Lindsey Graham (S.C.) are furiously whipping among their GOP colleagues this week would significantly cut federal Medicaid spending across the board. And it even contains a double whammy for the 30 or so states that accepted the Affordable Care Act's Medicaid expansion, reducing their share of the extra funding by spreading it across all 50 states in an effort to put all the states on a more equal playing field.

Cassidy lives in one of these states — Louisiana — that expanded Medicaid and stands to receive among the heftiest funding cuts if his bill is enacted. So does Nevada Sen. Dean Heller, who has also signed onto the Cassidy bill, and several other moderate Republicans whose votes are crucial to passing it -- including Alaska Sen. Lisa Murkowski, Ohio Sen. Rob Portman, Arizona Sen. John McCain and even Senate Majority Leader Mitch McConnell of Kentucky.

Republicans often complain about the federal government's burdensome Medicaid costs. But when push came to shove many were hesitant to go on record supporting a bill that deeply cut the program, as the Senate's Better Care Reconciliation Act would have done. Disputes over how to treat Medicaid — coupled with dissension over how much to regulate insurers and retain the ACA's consumer protections — ultimately brought down that bill and a few versions of it in July, when the Senate held several late-night votes in a desperate attempt to fulfill the GOP pledge to repeal and replace the ACA.

Republicans could very easily crash and burn again if they move forward with the Cassidy-Graham measure. But they're trying anyway, frantic that they'll lose out on potentially their last real chance to repeal the law they have made a political punching bag.

The Senate Finance Committee announced last night that it will hold a hearing next Monday on the measure. McConnell and his team will be trying to sell Graham-Cassidy at their weekly luncheon today. Senate Republicans have until only the end of next week to pass the measure before the budget reconciliation bill they're using as a vehicle expires. The House could pass the bill after that, but couldn't enact any changes.

Compared with the House and Senate health-care bills, the Graham-Cassidy measure would more drastically remold the ACA by giving states virtually unlimited control over federal dollars currently being spent on marketplace subsidies and Medicaid expansion. It also would allow states to opt out of virtually all the ACA’s insurer regulations by obtaining waivers.

It would work roughly like this: Starting in 2021, the federal government would lump together all the money it spends on subsidies distributed through the ACA marketplaces and expanded Medicaid programs covering poor, childless adults living at up to 133 percent of the federal poverty level.

The government would redistribute that money to states through what’s known as a block grant. These block grants would be based on a formula that, among other factors, takes into account the state’s share of low-income adults — an approach that would generally result in less money for states that expanded Medicaid and more money for states that didn’t.

So Texas, for example, would see an increase in its federal health-care funding, while states such as Alaska or Arizona (which both expanded Medicaid) would see a decrease. That could make it harder for Cassidy to convince senators from those states —  Sen. LIsa Murkowski (Alaska) and John McCain (Ariz.), who is being treated for brain cancer, to support his bill. Both helped sink the July effort.

By 2026, the federal government would be spending 17 percent less on subsidies and Medicaid expansion overall than under current projections, according to an analysis by the Center on Budget and Policy Priorities.

Then, in 2027, states would face a big fiscal cliff, when Graham-Cassidy would halt all that spending. That’s a major step further than the BCRA, which would have retained the marketplace subsidies (despite reducing them somewhat) and allowed states to keep Medicaid expansion (albeit paying for these enrollees at the normal matching rate and not the ACA’s expanded matching rate).

Here's a chart showing the funding dropoff:

The Graham-Cassidy bill does pretty closely mirror the BCRA in how it treats the regular Medicaid program. It would convert that program to a per capita system based on the number of enrollees in a state instead of the open-ended funding approach the federal government takes.

Under the measure, regular Medicaid funding (not including expansion) would be 8 percent lower by 2026; it would have been 9 percent lower that year under the BCRA.

But there’s another way Graham-Cassidy goes further than previous Obamacare rollback measures: It would allow states to opt out of the law’s “essential health benefits,” the baseline services that insurers must cover. That means there will no longer be a rock-solid prohibition on charging higher premiums to people with preexisting medical conditions, although states would need federal waivers.

The second version of the BCRA — which McConnell rolled out in mid-July with an amendment from Sen. Ted Cruz (R-Tex.) — would have allowed insurers to opt out of those regulations — but only if they also sold a fully ACA-compliant plan on the marketplaces.

(Here's another great explanation of how Graham-Cassidy would work, from my colleague Kim Soffen.)

The bottom line is this: The Cassidy bill will appeal to most conservatives in the House and the Senate, who can make the case to their base that they’re unshackling states from federal mandates and giving them huge leeway to construct a health-care approach that works best for them.

But if the moderate Republicans go along with this latest approach, they’d have to ignore the steep Medicaid cuts and insurance regulation rollbacks some had previously opposed.


--Is the momentum around Graham-Cassidy real? Senate leadership is sure trying to make it so. Many had assumed the GOP's Obamacare repeal effort was dead after that failed series of votes two months ago, which represented a substantial defeat to both McConnell and President Trump. But Republicans seem desperate to be able to tell their base in next year's midterm elections that they repealed Obamacare.

"The appearance of a new measure reflected just how damaging Republicans consider their inability to make good on a key campaign promise of the past seven years: to repeal and replace President Barack Obama’s signature domestic policy achievement," my colleagues Sean Sullivan and Kelsey Snell write. "But trying again brings its own perils. It remains far from certain that McConnell can marshal the 50 votes he needs to pass the measure. Already under fire from Trump for falling short in the earlier effort, McConnell could see his standing with the president and other Republicans suffer all the more if he fails again."

Sen. John Thune, one of McConnell's top lieutenants, credited Cassidy with reviving the repeal push. “I just told Bill Cassidy he’s a grave robber,” the South Dakota Republican said yesterday. “This thing was six feet under, and I think he’s revived it to the point where there’s a lot of positive buzz and forward momentum. But it still comes down to, in the Senate, getting 50 votes.”


--Vice President Pence has been making calls to GOP senators and governors in support of the bill. He's been viewed as the White House's most effective liaison with members of Congress because of the time he spent there. Pence plans to briefly leave the U.N. General Assembly meeting in New York to stop in at Senate lunches in the Capitol today.

--Republicans can afford to lose only two of their 52 senators. None of the three senators who voted against "skinny repeal" in July -- McCain, Murkowski and Maine's Susan Collins -- committed to voting for Graham-Cassidy yesterday, expressing reservations if not outright opposition.

Murkowski: She told reporters she was trying to learn more about the proposal’s impact on Alaska and consulting with her governor. On her way to McConnell’s office yesterday afternoon, the Alaskan wouldn’t say whether she was leaning for or against the bill.

Collins: She is viewed as the strongest opponent of replacing the ACA, and said yesterday she worries that millions could lose coverage under Graham-Cassidy.

McCain: He said that “we need more information. I need to talk to the governor again." (Arizona Gov. Doug Ducey notably endorsed the bill yesterday after opposing the BCRA.) McCain also reiterated his previously stated concerns about voting on a bill without ushering it through "regular order" i.e. committee hearings and markups. “We just need to have a regular process rather than, ‘Hey I’ve got an idea, let’s run this through the Senate and give them an up-or-down vote,’ ” he said.

McCain's words, per Bloomberg's Alex Ruoff:

The Senate Finance Committee has notably scheduled a hearing on Graham-Cassidy for next Monday. But Republicans are still rushing the process, as they don't yet have a score from the Congressional Budget Office (in fact, the CBO said yesterday it would only have a preliminary estimate to share next week, without any conclusions on how the measure would affect the deficit, how many people might lose insurance and whether premiums would spike.

HuffPost’s Igor Bobic speculated on how Republicans would react if Democrats approached a single-payer bill in the same fashion:


--Making this even more complicated, Sen. Rand Paul (R-Ken.) says he's a firm "no" because Graham-Cassidy would leave too much of the ACA in place. Paul voted against the BCRA in July, but he did support two subsequent votes on a delayed, partial repeal of the ACA and the "skinny" repeal bill ditching only small parts of it.

--With Paul out of the game, Republicans must nab either McCain, Murkowski or Collins. McConnell was working at least two of them yesterday, per Sean:




--This caught our eye: Cassidy's colleague John Kennedy, the other Republican senators from Louisiana, indicated yesterday he wants to move Graham-Cassidy even further to the right to ensure states couldn't use the money to set up a government-run, single-payer system.

"I think a single-payer system is a bad idea," Kennedy told the Washington Examiner yesterday. "I think if you give a big chunk of money to California they're going to go set up a single-payer system run by the state and then come back and say, 'We don't have enough money, we need more.' I think the only way we are going to solve the healthcare problem in America is through the private sector."

--Senate Minority Leader Chuck Schumer (D-N.Y.) dismissed the Cassidy bill as a way to hide a massive cut to Medicaid and said Republicans are moving forward without a complete assessment of who would be covered and how much it would cost. “It would be outrageous for our Republican colleagues to vote for this bill without knowing its effect on people,” he said. “That, whatever your ideology, would be nothing short of a disgrace.”

--Schumer warned that an attempt to vote on the measure poses a serious threat to ongoing, bipartisan negotiations on a plan to stabilize the ACA marketplaces and fund subsidies for out-of-pocket expenses. It could potentially upset talks between Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.) and the committee’s top Democrat, Sen. Patty Murray (Wash.), who say they're working toward an agreement this week.

--If the Senate passes Graham-Cassidy, would the more conservative House members fall into place? That's not at all clear, The Post's Mike DeBonis reportsOne might assume that the House, which already passed a GOP health-care bill in May, would simply rubber-stamp any Senate bill  and call it a day, but things are not quite so simple. The American Health Care Act (AHCA) passed the House 217-to-213, meaning two more dissenting voices would have stopped the bill cold.

“It will truly be a binary choice when it comes to the House for an up-or-down vote,” Rep. Mark Meadows (R-N.C.), chairman of the hard-right House Freedom Caucus, said Monday. “It’s going to be just a yes or no.”

"But none of those Republicans — cognizant of the many GOP health-care missteps to date — would guarantee Graham-Cassidy would pass the House," Mike writes. "Meadows, for one, said much depends on how the Senate bill might change in the coming weeks. Changing the bill too much to attract a GOP moderate like Sen. Lisa Murkowski could make the bill unpalatable to conservative hard-liners in the House, and Meadows said he and other House members are engaged behind the scene to prevent that from happening. For the time being, he said, he supports the bill and believes it will pass the House."

--Entertainer Jimmy Kimmel's stance on the bill doesn't exactly matter for its Senate prospects. But Kimmel did tweet a column by Post writer Jennifer Rubin, who wrote that Cassidy's own bill fails the "Jimmy Kimmel" test of ensuring people with preexisting conditions can get coverage. Cassidy coined the term during an appearance on Kimmel's show.


AHH: Trump's moves to cancel DACA, the Obama-era policy that gave a group of about 690,000 children and young adults known as "dreamers" assurances they could stay in the United States for at least two years, is reverberating through the health-care industry, Kaiser Health News reports.

"There are no firm statistics showing how many Dreamers work in the health care sector, but industry leaders suggested that DACA’s end could have an impact, especially among medical students and home health aides," Carmen Heredia Rodriguez and Ana B. Ibarra write.

"Multiple health care groups denounced the administration’s move. A statement released by the Association of American Medical Colleges (AAMC) said its members are “extremely dismayed” by the decision....The American Medical Association (AMA) said the administration’s announcement 'could have severe consequences for many in the health care workforce, impacting patients and our nation’s health care system.'"

"The more the administration threatens immigrants and their families and their communities,” said Robert Espinoza, vice president of policy at PHI, a long-term care advocacy group, “the more we threaten that workforce supply.”

One segment of the health-care workforce that could be affected is medical students. "Students and residents may have to cut their training short, the AAMC said, and researchers may have to leave the country before completing their experiments," Carmen and Ana write.

OOF: The liberal health care advocacy group Save My Care launched a digital ad campaign yesterday targeting Heller over his sponsorship of Graham-Cassidy, Talking Points Memo reports.

"Save My Care will not disclose the size of the ad buy, but told TPM it will target independent voters in Nevada on Twitter, Facebook, and other platforms," Alice Ollstein writes. "The ad features a cancer patient and cites a new study by the Center on Budget and Policy Priorities finding that the bill co-sponsored by Heller would allow states to waive some of Obamacare’s protections for people with pre-existing conditions."

The ad:

OUCH: Graham is making an interesting pitch about his measure. This is really all about stopping Democrats from passing the single-payer bill championed by Sen. Bernie Sanders (I-Vt.), Graham said Saturday during a radio interview with Breitbart, per Axios.

Graham described his bill as "Bernie Sanders' worst nightmare," saying Congress will either repeal the ACA or be stuck with "Berniecare," which he called "full-blown single-payer socialism."

"If you're not for this, then you really got to wonder whether or not you're a Republican," Graham said, asked about Republicans considering opposing his bill. "This is not about repealing and replacing Obamacare," he said. "This is about stopping a march towards socialism... this is the last best chance we will have to act and end Obamacare and stop Bernie-Care."

A few more good reads from around the World Wide Web:



  • Anthem and the Patient-Centered Outcomes Research Institute holds an event on the opioid crisis with Sen. Shelley Moore Capito (R-W.Va.).

  • The Center for Strategic and International Studies holds an event on the drug war and opioid epidemic.

  • Harvard’s School of Public Health holds an event on single-payer health care with Vermont’s former Gov. Peter Shumlin (D).

  • Bloomberg holds a health care event.

  • Roll Call holds an event on mental health.

Coming Up

  • The Washington Post holds an event on health care on Wednesday.


Fact Check: Does Medicare have less administrative costs than private insurers?

Democratic lawmakers are using fuzzy numbers to make a politically advantageous point. (Meg Kelly/The Washington Post)

Who spun it best?

Former high-profile White House staffers Sean Spicer, Steve Bannon, and Anthony Scaramucci are staying loyal to President Trump as they try to carve out new lucrative or influential roles. (TWP)