It’s safe to say the new Obamacare rollback measure toward which the Senate is charging would mean fewer Americans have health coverage. Exactly how many is unclear. Some argue it could be more than 22 million people. Others told me it could be fewer.
Why is 22 million an important figure? It’s how many more people would lack coverage under the Better Care Reconciliation Act ― the health-care bill the Senate tried and failed to pass back in July. That unsavory figure haunted Republicans as they tried to defend already unpopular legislation. They found out the hard way that it’s not so easy to win over the public on policy that nudged up the uninsured rate.
Republicans won’t have to combat a similar number if they vote on the Cassidy-Graham bill next week, which Senate Majority Leader Mitch McConnell (R-Ky.) has announced he intends to bring to the floor. That’s because the Congressional Budget Office ― the official scorekeeper for the legislative branch ― says it will release only a partial analysis by then. It will take several more weeks to estimate the bill’s costs and how many more people may be uninsured than under Obamacare.
On one hand, voting without this key information just means Republicans will endure more criticisms that they’re ignoring the measure’s impact on a sizable segment of the U.S. population. On the other, it means they’re not up against another big, scary number from the CBO at the moment.
And yet the question remains: How would the bill repealing and replacing parts of the Affordable Care Act, advanced by Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.), affect coverage?
We have a few clues.
A big reason for the coverage reductions under the BCRA was because it would have trashed the requirement to buy coverage or pay a fine (the individual mandate). The CBO has previously estimated that would result in about 15 million fewer people buying plans right off the bat (although many conservatives feel the agency overestimated the mandate’s effect).
Cassidy-Graham also gets rid of the individual mandate. So it appears the measure would result in at least 15 million fewer insured Americans, if the CBO uses the same methods.
But how would cuts to Medicaid and marketplace subsidies further affect coverage rates? Cassidy-Graham actually enacts cuts to traditional Medicaid that are comparable to those envisioned under BCRA, reducing spending on the program by about 8 percent by 2026. And, up until 2027, when there’s a big funding cliff, Cassidy-Graham appears to maintain more of the funding for subsidies and Medicaid expansion than BCRA.
Under BCRA, the federal government would spend $389 billion less on subsidies between 2020 and 2026, according to the CBO. But under Cassidy-Graham, it would spend $243 billion less during the same period on subsidies and Medicaid expansion combined, according to a projection by the left-leaning Center on Budget and Policy Priorities. Avalere Health set the figure at $215 billion in an analysis it released yesterday. (Neither group had figures for subsidy spending alone).
So some conservatives argue that Cassidy-Graham could feasibly result in more people receiving coverage than under BCRA ― depending on how states implement it.
“States could take the fact they’ve regained control of the insurance rules in their markets and have a lot of money from the federal government and could end up with something that covers a lot more people,” former CBO director Doug Holtz-Eakin told me. “I can make the case they could beat that number.”
Assumptions about how states will behave are key here. Under Cassidy-Graham, the federal dollars used for subsidies and Medicaid expansion would go to the states in a lump sum they could use in a huge variety of ways. That makes calculating the coverage effects of the Cassidy-Graham bill decidedly difficult, experts say.
For the CBO to come up with a ballpark figure for how many people would have health coverage under the GOP measure, the agency must make a whole lot of assumptions about how states would spend the money. They could do a heck of a lotta things with it, like setting up high-risk pools or covering cost-sharing subsidies ― or even continuing premium subsidies. To top it off, 36 states are holding governors races next year, making it incredibly difficult to predict how they’d all act.
These reasons are why health-policy firn Avalere hasn’t yet released an estimate of how many people would have coverage under Cassidy-Graham, the group’s founder, Dan Mendelson, told me. It’s a little easier to make assumptions about how states like California or New York, which are more actively involved in providing care to residents, would act than to guess the behavior of less-involved states like, say, Mississippi or Kansas.
“It is very dependent on state decision-making,” Mendelson said.
Of course, you could also assume states would use the money in ways that would result in many fewer people getting coverage ― potentially meaning Cassidy-Graham would get a CBO score even worse than the 22 million figure we’ve already discussed.
The Commonwealth Fund’s Sara Collins says the bill has the potential for massive coverage losses, especially when you consider states would have only a short time frame (until 2020) to set up their own coverage schemes.
“You kind of have this black hole where states are going to have some money but they don’t have the administrative structures in place,” she said.
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AHH: Sen. Chuck Grassley is famous (or infamous) for his candid approach on Twitter. The Iowa Republican was similarly forthright yesterday on a conference call with local reporters, where he said he supports the Cassidy-Graham plan but doesn't actually think it will pass. And the senator fingered politics as the driving force behind the bill.
From the Des Moines Register: “You know, I could maybe give you 10 reasons why this bill shouldn’t be considered,” Grassley said. “But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill. I think we’re one or two votes short and I don’t see those other one or two votes coming...I hope I’m wrong.”
How the Des Moines Register's Jason Noble framed it:
My colleague Paul Kane has more on the motivation driving Senate Republicans to put something, anything, on the floor in a smart column this morning. During the five-week August recess, Paul writes that GOPers got plenty of blowback for breaking their longstanding vow to repeal Obamacare. "... according to GOP senators and aides, Republicans faced an unrelenting barrage of confrontations with some of their closest supporters, donors and friends. The moments occurred in small gatherings that proved even more meaningful than a caustic town hall — at meetings with local business executives, at church, at parks ...
"It didn’t matter if those friends and allies were big-time supporters of President Trump or part of the 'Never Trump' crowd of purist conservatives opposed to his hostile takeover of the GOP. By August, those two wings came together in their sheer, utter contempt toward a Republican-controlled Congress that could not back up its most basic promise, to repeal Obamacare. Trump’s hectoring via social media egged them all on."
OOF: Former President Obama said any effort to repeal his namesake law would end up "inflicting real human suffering" on those who'd gained coverage and consumer protections under it, speaking yesterday at an event hosted by the Bill & Melinda Gates Foundation. It's "aggravating" to watch GOP leaders try to roll back the ACA, Obama said, calling his law not "perfect, but better."
“And it’s certainly frustrating to have to mobilize every couple of months to keep our leaders from inflicting real human suffering on our constituents,” Obama added. “But typically, that is how progress is won and how progress is maintained on every single issue.”
--Graham had a quick response: “It’s unrealistic to expect President Obama would acknowledge his signature issue is failing," he said in a statement. “It’s no surprise President Obama opposes sending money and power back to the states and closer to where the patients live...Obamacare was designed with the exact opposite goal in mind — which is to consolidate health care power and decision-making in Washington.”
Watch Obama's comments:
OUCH: Jimmy Kimmel wants everyone to know he's still giving Cassidy a big, fat "F" on his health-care bill. The late-night host saw his Tuesday night monologue about health care go viral after he tore into Cassidy for his legislation, which would open the door to insurers potentially charging higher premiums to those with preexisting medical conditions.
Kimmel has taken particular issue with Cassidy because the Louisiana senator appeared on his show in May and said he would oppose a bill in which people with preexisting conditions were not protected, nicknaming some of these guidelines the “Jimmy Kimmel test,” as it was right after Kimmel had publicly discussed his newborn son’s harrowing open heart surgery. Kimmel unloaded again last night on Cassidy, who had responded on CNN that Kimmel "doesn't understand" the measure.
Sen. Bill Cassidy responds to Jimmy Kimmel: “I’m sorry he does not understand.” Under new health care bill “more people will have coverage” pic.twitter.com/tOGCWkqoeE— CNN (@CNN) September 20, 2017
“Oh, I get it, I don’t understand because I’m a talk show host, right?," Kimmel said. "Well, then help me out. Which part don’t I understand? The part where you cut $243 billion from federal health-care assistance? Am I not understanding the part where states would be allowed to let insurance companies price you out of coverage for having preexisting conditions? Maybe I don’t understand the part of your bill in which federal funding disappears completely after 2026? Or maybe it was the part where the plans are no longer required to pay for essential health benefits like maternity care or pediatric visits?"
Watch Kimmel here:
So how well does Kimmel understand the Cassidy bill? The Post's Amber Phillips lists five of Kimmel's claims that matched up to what we know about the measure.
--Graham defended his colleague. “I wished he would've called Senator Cassidy to ask him, ‘Is what I'm reading true?’" Graham said of Kimmel, speaking to NBC. "'Cause you heard some liberal talking points that are absolute garbage. He bought it hook, line, and sinker. He didn't give him the courtesy of hearing his side of the story. He went on national TV and called this man, who has worked for the underprivileged and health care all of his life, a liar, and I think that's inappropriate.”
--President Trump also leapt to Cassidy's defense in a series of tweets yesterday where he heaped praise on the Louisiana Republican and promised his bill would indeed protect people with preexisting conditions. (Cassidy-Graham does open the door to charging higher premiums to people with preexisting conditions through a state waiver process, but it retains a requirement known as guaranteed issue that insurers must cover them.)
Senator (Doctor) Bill Cassidy is a class act who really cares about people and their Health(care), he doesn't lie-just wants to help people!— Donald J. Trump (@realDonaldTrump) September 21, 2017
I would not sign Graham-Cassidy if it did not include coverage of pre-existing conditions. It does! A great Bill. Repeal & Replace.— Donald J. Trump (@realDonaldTrump) September 20, 2017
I hope Republican Senators will vote for Graham-Cassidy and fulfill their promise to Repeal & Replace ObamaCare. Money direct to States!— Donald J. Trump (@realDonaldTrump) September 20, 2017
Rand Paul is a friend of mine but he is such a negative force when it comes to fixing healthcare. Graham-Cassidy Bill is GREAT! Ends Ocare!— Donald J. Trump (@realDonaldTrump) September 20, 2017
--The comments are Trump's first public endorsement of the effort, my colleague Abby Phillip reports. "It is not clear, however, what effect Trump's endorsement will have. He has made private phone calls to lawmakers in the past week, according to administration officials. But until now, he had avoided making public comments on the bill, a stark contrast to his engagement on previous failed efforts to repeal and replace the Affordable Care Act."
Shortly after the president's tweets, Paul responded with his own tweets, renewing his criticism of the bill:
The #GrahamCassidy Obamacare Amnesty bill would be one of the largest new appropriations in our history, costing taxpayers over $1 Trillion— Senator Rand Paul (@RandPaul) September 20, 2017
How on earth could a trillion dollar appropriation be considered conservative or a repeal of Obamacare? It is neither— Senator Rand Paul (@RandPaul) September 20, 2017
This new "gang" bill is another Grahamnesty, this time for Obamacare. Conservatives have seen this before.— Senator Rand Paul (@RandPaul) September 20, 2017
--Why all the rush to pass a health-care bill? My colleague Elise Viebeck lays out the complicated legislative details explaining why the GOP is in such a hurry to act by Oct. 1. “The answer lies in a combination of Republican legislative strategy, arcane Senate procedure and ordinary partisan divisions," Elise writes. "But it boils down to the fact that on Oct. 1, the number of votes needed to pass Cassidy-Graham will rise above the number of Republicans in the Senate, effectively blocking the bill’s path."
What you need to know:
--The Senate has until Sept. 30 to approve Cassidy-Graham with a simple majority of votes rather than the usual 60 needed for most legislation.
--The Sept. 30 deadline exists because of a process known as budget reconciliation, which allows some fiscal measures to pass without the usual 60 votes. Republicans set this process in motion at the beginning of the year, when they passed a budget bill that included instructions for two committees to begin work on health-care legislation with the goal of saving federal revenue.
--Those instructions expire at the end of the fiscal year that’s covered under the budget bill. Senators could always write new instructions into their next budget, but they were planning to use that opportunity to direct a different legislative priority — tax cuts.
--Yesterday also brought a slew of new opposition to Cassidy-Graham, most notably an announcement by the major insurer association America's Health Insurance Plans that it will oppose the bill. That's a pretty big deal, since AHIP hadn't come out against any of the GOP's previous health-care bills.
New Jersey Gov. Chris Christie (R), the Blue Cross Blue Shield Association and the Federation of American Hospitals also expressed deep hesitations about the measure or said they oppose it altogether, as former CMS Administrator Andy Slavitt noted:
BREAKING: In the last hour, Chris Christie, AHIP (Insurers), Blue Cross, Fed of Amer Hospitals announced Graham-Cassidy opposition.— Andy Slavitt (@ASlavitt) September 20, 2017
And many noted that McConnell's intention to bring the measure to the floor doesn't mean he has 50 votes -- it could just be his way of heaping pressure on hesitant senators like Arizona's John McCain and Alaska's Lisa Murkowski to hurry up and decide.
MSNBC's Garrett Haake:
This could also be a pure pressure tactic: McCain, Murkowski, Collins, Portman, Gardner, Lee, Cruz -none have publicly said how they'll vote https://t.co/gICYMrDCUA— Garrett Haake (@GarrettHaake) September 20, 2017
Politico White House reporter Josh Dawsey:
One of my favorite quotes from Trent Lott: "When you don't got the votes, you strategize and talk. When you got the votes, you vote."— Josh Dawsey (@jdawsey1) September 20, 2017
McCain's been calling for putting the measure through the committee hearing process, known as "regular order." Bloomberg's Sahil Kapur made us LOL:
McCain enters his fav restaurant— Sahil Kapur (@sahilkapur) September 20, 2017
Hey guys, I'll have my
Wanna keep up with where senators stand on Cassidy-Graham? Follow along with The Post's whip count here.
--Murkowski could be the GOP senator to sink this thing. “Murkowski’s status as one of at least four Republicans who remain unsure whether to support legislation that leaders hope to pass by the end of the month has pushed her, again, to the middle of the action this week," The Post's Sean Sullivan reports. "But there’s another reason the public’s attention tends to lock on this warm yet resolute and sometimes brusque senator: No one has any idea what she will do.
"Like the state she represents, Murkowski projects an independent streak," Sean writes. "She regularly breaks with her party, yet she is also willing to play ball. Alaska is mysterious, complicated and needy. So is its senior senator."
“The problem last time was process and substance,” Murkowski said Tuesday after her pause in the Capitol, explaining why she might be willing to support the current measure despite voting against the last one in July. “Nobody knew what we were really looking to in voting on.”
- The National Institute for Health Care Management Foundation holds a webinar on navigating care choices on Friday.
- The American Enterprise Institute holds an event on “Innovative rethinking of health care delivery and competition” on September 29.
President Trump says the latest GOP health-care bill has a 'very good chance' of passing:
Melania Trump discusses bullying at a U.N. luncheon:
Samantha Bee asks: "Is there any hope for the Left?"
And Jeff Flake is a "yes" on Cassidy-Graham: