As Senate Republicans work feverishly to try to revive plans to replace parts of the Affordable Care Act ahead of a Sept. 30 deadline, it’s easy to forget: There’s another chamber in Congress, and it is not a potted plant.
And it is not at all clear that the bill being crafted in the Senate by Sens. Lindsey O. Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.) and Ron Johnson (R-Wis.) — known widely as Graham-Cassidy — would prompt House Republicans to fall in line should it pass the Senate.
Make no mistake, the pressure on GOP House members to make good on their eight-year promise to repeal the Affordable Care Act would be enormous, and several House Republican aides and members said Monday that they expect members would be squeezed in a political vise of epic proportions until the measure passes.
“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.
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 (Alaska) 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.
But the bigger obstacle may be House moderates — particularly from the states of California and New York, which stand to lose tens of billions of dollars in federal health-care funding under the Graham-Cassidy framework. The bill as currently structured takes the money already set to be sent to states for Medicaid and ACA subsidies, pools it, and distributes it as few-strings-attached block grants.
The catch is that it would be distributed to both states that did expand their Medicaid programs under the ACA and to those that didn’t — meaning large states that expanded would lose billions. An analysis by the liberal Center for Budget and Policy Priorities estimates New York would lose about $19 billion after 10 years, and California would lose nearly $28 billion.
Together, 21 GOP lawmakers from California and New York voted for the American Health Care Act in May, and a threshold question for considering Graham-Cassidy’s prospects is to wonder how many of them will be willing to vote to blow a hole in their state’s health-care budget.
There are early signs of concern. Rep. Peter T. King (R-N.Y.) said in an interview Monday that “New York is actually going to do worse as far as Medicaid funds than it did” under the ACHA.
“Right now, I don’t see how I could vote for it,” he said. “It’s extremely damaging to New York.”
King said his AHCA vote — like those cast by other House moderates — was predicated on the fact that it would not be a final vote: The Senate, the thinking went, would intervene to roll back the AHCA’s Medicaid cuts, leaving a more palatable product for lawmakers like King. And if it was not palatable enough, they made clear, they would withhold their support.
But there is no doubt whatsoever a House vote on Graham-Cassidy will be final. Due to the vagaries of Senate rules, that chamber will not be able to revisit the bill after the Sept. 30 deadline, so the House will be unable to make changes and send them back to the Senate for passage by a simple 50-vote majority.
That makes the grumbling from moderates like King worth paying attention to.
“Whether it was right to have the Medicaid expansion in the first place, the fact is, it’s in place now,” King said. “You have local governments and hospitals, basically the health-care apparatus in New York, is conditioned and based upon getting that funding, and it would be extremely damaging.”
Graham and Cassidy, he continued, are “both good guys. I don’t see any malice in what they’re trying to do. But again in getting what they see as a national consensus, to do that they’ve had to appeal to the rural states at the expense of the urban, suburban states like New York. So as of now, I’m a no, and I don’t see myself changing on that.”
King is not the only moderate raising concerns. Another New Yorker, Rep. Tom Reed (R), gave a cautious assessment of the bill in a statement Monday.
“We are waiting to see if this in fact comes out of the Senate,” he said. “I would be concerned that the Faso-Collins amendment which is critically important for New Yorkers, isn’t included. But to be honest, I’m not overly optimistic the Senate will move this forward.”
Faso-Collins was an AHCA amendment negotiated precisely to win the votes of the moderate New Yorkers, aimed at a state government practice in the Empire State that forces counties to raise local revenue to support the Medicaid program, driving up property levies in much of the state. But the deal was stripped out in the Senate, and it is not included in Graham-Cassidy.
The conventional wisdom on Capitol Hill, as it happens, is that the moderates always cave, that it’s the hard-liners in the Freedom Caucus you have to worry about when passing a tough bill in today’s Republican House. If the Senate coughs up a health-care bill later this month, that thinking could be tested.
Meadows said it was “too early to tell” whether Freedom Caucus members would embrace Graham-Cassidy given the lack of a final Senate product — all but one of the group’s members backed the AHCA after weeks of wrangling — but he said the bill as currently drafted has his support, and he doubted many House Republicans would ultimately break their campaign promises.
“It’s either do this bill or rely on the president to do what he can do administratively from here on out, and, to be frank, there is just a whole lot of bad scenarios that will come home to roost if we don’t address this,” he said. “So I see Sept. 30 being either a great day or a devastating day as it relates to lowering premiums in the months and years ahead.”