with Paulina Firozi


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. (Jenny Starrs/The Washington Post)

Republicans are fixated on the latest version of their Obamacare overhaul legislation. But in their haste to secure approval, they’ve not exactly won over their deepest skeptics, who objected to the last dramatic repeal-and-replace go-round.

Doctors, hospitals, insurers, activists and governors have been staking out their positions on the Graham-Cassidy bill, which the White House and leadership are furiously pitching this week to Senate Republicans as their final chance to ditch the Affordable Care Act.

It goes without saying that in the liberal camp, all the groups and politicians opposed to the last batch of ACA rollback bills are fighting Graham-Cassidy, too. But their opposition is only peripheral to the bill’s prospects, because Republicans were never going to win over progressives anyway.

But more significantly, Republicans still haven’t managed to win over industry groups — or convince some moderate Republican governors who worried that the previous plans would leave millions of Americans uninsured. Nor are many of the conservative activist groups — who were the most insistent on Obamacare repeal to begin with — terribly enthused about Graham-Cassidy, since they feel it would leave too much of the ACA in place.

Now, heavy opposition doesn’t necessarily mean Republicans will desist. After all, the House passed a health-care bill this year that was deeply unpopular. For many congressional Republicans, passing a health-care bill was always more about getting rid of President Barack Obama's landmark legislation than building consensus around a replacement plan.

And don’t underestimate the power of a tight timeline to light a fire under Congress. When three repeal bills failed in the Senate over the summer, Republicans knew they could always return to the effort. But now they have less than two weeks before the legislative vehicle they’re using expires. Dealbreakers in July are not always dealbreakers in September, as one lobbyist told me.

Furthermore, the White House is all in, dispatching Vice President Pence and other top officials to Capitol Hill yesterday to make the case for Graham-Cassidy.

“I’m going to make the case: This is the moment, now is the time,” Pence told reporters on Air Force Two. “We have 12 days.”

Top GOP policy wonk Lanhee Chen told me he’s more bullish about prospects for Graham-Cassidy than he was for the Better Care Reconciliation Act that failed in the Senate two months ago.

“The energy is there, much more so than we saw during the [Better Care Reconciliation Act] debate earlier,” Chen said. “The White House is much more engaged than I ever saw them during the Senate debate, too. I would take it seriously.”

Yet it will be no big surprise if Republicans fall one or two votes short of the 50 votes they need to pass Graham-Cassidy. Skeptical moderates are getting heavy pressure from many sides to reject it.

Here’s a look at where key stakeholders are lining up on the bill:


—American Hospital Association: “We believe that coverage could be at risk for tens of millions of Americans under the Graham-Cassidy proposal. This proposal would erode key protections for patients and consumers and does nothing to stabilize the insurance market now or in the long term,” the AHA said in a statement.

—America's Essential Hospitals: “Policy changes must maintain coverage for those who have it, preserve access and protect hospitals that care for low-income and other vulnerable people. While we do not yet have a Congressional Budget Office score for the Graham-Cassidy proposal, the plan appears to violate those core principles,” the group said.

—Six doctors’ groups that allied to oppose the BCRA are also staunchly opposed to Graham-Cassidy. They include the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association and the American Psychiatric Association.

Here’s what they said: “The proposal fails to protect the health care coverage and consumer protections available under current law.”

—American Medical Association: “Unfortunately, the Graham-Cassidy Amendment … violates the precept of 'first do no harm’…we believe the Graham-Cassidy Amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care,” it said.

—America’s Health Insurance Plans hasn’t taken a position on Graham-Cassidy, a spokeswoman told The Health 202.


—Five Republican governors whose states expanded Medicaid signed a bipartisan letter in July opposing the “skinny repeal” bill. They included John Kasich of Ohio, Brian Sandoval of Nevada, Charlie Baker of Massachusetts, Larry Hogan of Maryland and Phil Scott of Vermont.

Four of those Republicans (but not Hogan) signed a letter yesterday opposing Graham-Cassidy. Bill Walker of Alaska, an independent, signed it, too, along with five Democratic governors. They said senators should pursue a “bipartisan effort” to stabilize the marketplaces instead of legislation only Republicans support.

“Only open, bipartisan approaches can achieve true, lasting reforms,” they wrote.

Walker's opposition didn't prompt his state's Republican senator, Lisa Murkowski, to swing against the bill (at least yet), The Post's Sean Sullivan noted:

It's interesting that Sandoval is against the bill, since Nevada Sen. Dean Heller is one of its co-sponsors. From a columnist at the Las Vegas Review Journal: 

A comment from former Kasich strategist, John Weaver:

As a side note, Ed Gillespie (the former Republican National Committee Chairman who's running for Virginia governor this year) also isn't supportive, per MSNBC's Kailani Koenig: 

—But one key Republican governor in a state that expanded Medicaid — Arizona’s Doug Ducey — endorsed it on Monday. The statement he tweeted out:

--Fifteen other Republican governors also backed Graham-Cassidy yesterday, writing in a letter to leadership that its flexible block grants are the "last, best hope" to replace Obamacare. Three of them -- Kentucky's Matt Bevin, Indiana's Eric Holcomb and Arkansas' Asa Hutchinson -- are notably from states that accepted the ACA's Medicaid expansion. The letter, per Bloomberg's Sahil Kapur:

CONSERVATIVE ACTIVISTS: Cautiously supportive.

—Heritage Foundation: Hasn’t taken a position, although a spokeswoman said the group plans to offer a brief on it this week. Last week, Heritage Action communications director Dan Holler said this: “What has been proposed isn’t actually repeal and replace … I’m not convinced that the solution here is to unveil another sweeping bill ahead of a tight deadline.”

—FreedomWorks: Graham-Cassidy is “far from perfect, and it’s not the repeal of Obamacare that was promised,” Jason Pye, the group’s vice president of legislative affairs, wrote in a blog post over the weekend. “Nevertheless, FreedomWorks is treating it as what is likely to be the last serious attempt at health insurance reform before the Sept. 30 deadline for reconciliation.”

—Americans for Prosperity: “Based on the current legislative text, questions still remain about whether this bill would include enough regulatory relief to actually bring health insurance costs down and create more options in the market, but we continue to seek more clarity on this issue," the group's Chief Government Affairs Officer Brent Gardner told me in a statement. "We look forward to continuing to work with lawmakers on strengthening this legislation."

—Tea Party Patriots: “The majority of our supporters do not support the Graham-Cassidy bill, and a supermajority still demand that Republicans live up to their promises to fully repeal Obamacare. Nevertheless, these same people believe Tea Party Patriots should support Graham-Cassidy as a step toward full repeal,” the group said in a statement.

—Club for Growth: “While it is better than Obamacare, there’s no doubt this legislation still falls far short of a full repeal and does not do enough to lower health insurance costs … One proposal that would do much to strengthen this legislation is Senator Cruz’s revised Consumer Freedom amendment to roll back the harmful and costly regulations at the heart of Obamacare … If this change is incorporated in the final version of the Graham-Cassidy legislation, Club for Growth will plan to support the bill,” the group said.


AHH: Researchers from the Centers for Disease Control and Prevention published an analysis yesterday showing the opioid abuse crisis is so bad that it's hurt life expectancy in the United States. They found that the average American life expectancy grew overall from 2000 to 2015, but that the astounding rise in opioid-related deaths shaved 2.5 months off this improvement, The Post's Kyle Swenson and Travis M. Andrews report.

"That’s .21 years, compared to the .02 years taken off the average life expectancy by alcohol overdose," Kyle and Travis write. "No factor negatively affected life expectancy more. The average life expectancy for an American born in 2010 was 76.8 years, which grew to 78.8 years in 2015. The study suggested that but for opioid-related deaths, it would have been higher still....Opioid overdose still hasn’t cracked the top 12 leading causes of death — which, aside from suicide and unintentional injuries, are all medical conditions — but it’s close."

OOF: Last week, Health and Human Services Secretary Tom Price took private jets on five separate flights for official business, costing the government tens of thousands of dollars more than commercial travel, according to a report by Politico. The travel by corporate-style jet breaks with the practice of Price's predecessors Sylvia Mathews Burwell and Kathleen Sebelius, who flew commercially.

"The secretary’s five flights, which were scheduled between Sept. 13 and Sept. 15, took him to a resort in Maine where he participated in a Q&A discussion with a health care industry CEO, and to community health centers in New Hampshire and Pennsylvania, according to internal HHS documents," write Dan Diamond and Rachana Pradhan. "HHS spokespeople declined to confirm details of the flights, or respond to questions about who paid for them, with a spokesperson only saying that Price sometimes charters planes when commercial flights aren’t feasible."

“As part of the HHS mission to enhance and protect the health and well-being of the American people, Secretary Price travels on occasion outside Washington to meet face to face with the American people to hear their thoughts and concerns firsthand,” an HHS spokesperson said, adding, “When commercial aircraft cannot reasonably accommodate travel requirements, charter aircraft can be used for official travel.”

"Price’s spokespeople declined to comment on why he considered commercial travel to be unfeasible," Dan and Rachana report. "On one leg of the trip – a sprint from Dulles International Airport to Philadelphia International Airport, a distance of 135 miles – there was a commercial flight that departed at roughly the same time: Price’s charter left Dulles at 8:27 a.m., and a United Airlines flight departed for Philadelphia at 8:22 a.m., according to airport records."

OUCH: Remember that "Jimmy Kimmel test"  coined by Cassidy back in May? Kimmel said last night that Cassidy has failed it -- badly.

A few days after the late-night host revealed that his newborn son, Billy, was born with a heart defect that required immediate surgery, Cassidy appeared on his show. During their conversation, as they talked about whether insurance companies should be able to cap payouts, Cassidy reiterated the importance of making sure people with preexisting conditions should be able to afford health-care, framing the issue as the "Jimmy Kimmel test."

On his show Tuesday night, Kimmel eviscerated Cassidy and his bill:

“I know you guys are going to find this hard to believe. But a few months ago, after my son had open heart surgery … a senator named Bill Cassidy from Louisiana, was on my show and he wasn’t very honest,” Kimmel said, kicking things off. "This new bill actually does pass the Jimmy Kimmel test, but a different Jimmy Kimmel test. With this one, your child with a preexisting condition will get the care he needs — if, and only if, his father is Jimmy Kimmel. Otherwise, you might be screwed."

"If the bill passes, individual states can let insurance companies charge you more if you have a preexisting condition. You’ll find that little loophole later in the document after it says they can’t. They can, and they will....This guy, Bill Cassidy, just lied right to my face," Kimmel added.

Kimmel tweeted this, too:


--With Senate Republicans suddenly focusing their energy on Graham-Cassidy -- much to the chagrin of Democrats --- that bipartisan effort between the two HELP committee leaders to stabilize the ACA marketplaces has basically been sidelined, the committee's chairman Lamar Alexander (R-Tenn.) admitted yesterday. He downplayed expectations that he could reach a deal with ranking member Patty Murray (D-Wash.)

“During the last month, we have worked hard and in good faith but have not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders’ hands that could be enacted,” Alexander said in a statement.

Democrats denied that the talks had fallen apart, accusing Republicans of walking away despite making progress on areas of disagreement. Senate Minority Leader Chuck Schumer's (D-N.Y.) spokesman Matt House said Democrats offered to accept a number of GOP requests, including waivers to give states more latitude in how they spend federal dollars and the creation of new low-cost plans under the ACA.

“This is not about substance,” House said in a statement. “The Republican leadership is so eager to pass Graham-Cassidy that they’re scuttling a balanced, bipartisan negotiation.”

Murray said she hoped the talks could still be salvaged. “I am disappointed that Republican leaders have decided to freeze this bipartisan approach,” she said in a statement. “But I am confident that we can reach a deal if we keep working together.”

--Senate Democrats, who spent weeks thinking they won the fight to keep the ACA in place, are mobilizing alongside progressive activists for 11 more days on the defensive.

“They’re going to hear from us one more time!” Senate Minority Leader Charles E. Schumer (D-N.Y.) said at a Tuesday afternoon rally outside the Capitol. “Protesting, picketing, emailing — you name it!”

"The multilevel campaign to block the Republican bill consists of everything progressives did to stop previous iterations — from “melting the phones” of Republican senators to waging sit-ins at their offices," my colleague Dave Weigel reports. "This time, activists admit, feels different and more desperate. There’s fear that Senate Republicans learned from their first failed attempt at repeal, as House Republicans did in March. There’s some bitterness directed toward Senate Democrats, who cut a deal on the debt limit with President Trump — one that infuriated Republicans, but also created an opening on the calendar before the GOP’s Sept. 30 deadline to pass a bill with a bare majority."

“That was a blunder on the part of Democrats,” said Angel Padilla, the policy director of the grass-roots Indivisible coalition. “Why not wait until September 30 to cut that deal? We would have otherwise been talking about the debt ceiling and disaster relief.”

--Vice President Pence has launched a full-court press. He let Graham ride with him on Air Force Two, before the two went to the GOP policy lunch at the Capitol building. Here are some of the things Pence told Graham, from the pool report:

"My message today is I want to make sure that members of the Senate know the president and our entire administration supports Graham-Cassidy. We think the American people need this.

"I'm going to make it clear that the House will not support efforts to fix or prop up Obamacare. The speaker made that clear today, as he also expressed his support [for Graham-Cassidy.] And I'm going to make the case: this is the moment, now is the time. We have 12 days."

Graham praised Pence's negotiating power to Axios reporter Jonathan Swan, per the AP's Ken Thomas: 

Some good reads from The Post and beyond:



  • The Washington Post holds an event as part of its signature Transformers series, and will feature doctors, researchers, scientists, medical technology pioneers and business leaders who are pushing boundaries in the health sector and transforming the way we live.
  • The National Coalition on Health Care holds an event on “Strengthening the Primary Care Workforce.”

Coming Up

  • The American Enterprise Institute holds an event on “Innovative rethinking of health care delivery and competition” on September 29.

Sen. Lindsey O. Graham (R-S.C.) positions his health-care plan as a choice between 'socialism or federalism':

Sen. Lindsey O. Graham (R-S.C.) painted a dark picture of health care in the U.S. if the Cassidy-Graham plan doesn't pass on Sept. 19. (The Washington Post)

Sen. Bill Cassidy (R-La.): If your state 'has not expanded Medicaid, you're going to do great':

Sen. Bill Cassidy (R-La.) said his health-care plan will return money to the states "to do that which is best for that state," on Sept. 19. (The Washington Post)

Senate Majority Mitch McConnell (R-Ky.): 'The opportunity expires at the end of the month' for health-care vote:

Senate Majority Leader Mitch McConnell (R-Ky.) said on Sept. 19 "we would have to act before Sept. 30" to pass a health-care bill under reconciliation rules. (The Washington Post)

Sen. Lindsey O. Graham (R-S.C.) says Trump is 'focused like a laser' on health care:

Sen. Lindsey O. Graham (R-S.C.) said President Trump "is very excited about this state-centric health-care system" on Sept. 19. (The Washington Post)

Sen. Charles E. Schumer (D-N.Y.) slams "the latest version of Trumpcare":

Sen. Charles E. Schumer (D-N.Y.) attacked the latest GOP health-care plan, the Cassidy-Graham proposal, on Sept. 19 as 10 governors came out against it. (The Washington Post)

Some highlights in honor of The Fact Checker's 10th anniversary:

For the past 10 years, the Fact Checker has examined the statements of leading politicians. (Meg Kelly/The Washington Post)

Watch Stephen Colbert hand Hillary Clinton a "cheeky" dossier of unused election night jokes: