https://www.yahoo.com/news/trump-lashes-gop-opponents-health-care-bill-110647029–politics.html

“I cannot in good conscience vote for the Graham-Cassidy proposal,” McCain said in a statement, referring to the bill by Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana.

“I believe we could do better working together, Republicans and Democrats, and have not yet really tried,” he said. “Nor could I support it without knowing how much it will cost, how it will affect insurance premiums, and how many people will be helped or hurt by it.”

McCain was the decisive vote against the GOP’s last repeal effort, in July. Once again, the 81-year-old senator, battling brain cancer in the twilight of a remarkable career, emerged as the destroyer of his own party’s signature promise to voters.

President Donald Trump and Senate Majority Leader Mitch McConnell had both been pushing hard for the bill in recent days, and McCain’s best friend in the Senate, Graham, was an author. Trump declared during the presidential campaign that he would quickly demolish Obamacare and “it will be easy.”

McCain’s announcement likely leaves GOP leaders at least one vote short for the bill, which they had hoped to bring to the floor next week. They face a Sept. 30 deadline for action on the legislation, at which point special rules that prevent a Democratic filibuster will expire.

Democrats are unanimously opposed. GOP Sen. Rand Paul of Kentucky has announced his opposition and GOP Sen. Susan Collins of Maine said Friday she, too, was leaning against supporting the bill.

Along with McCain, that would leave Republicans with only 49 votes for the bill; they would need 50, plus Vice President Mike Pence to break a tie, in order to prevail.

The Graham-Cassidy bill would repeal major pillars of former President Barack Obama’s law, replacing them with block grants to states to design their own programs. Major medical groups are opposed, saying millions would lose insurance coverage and protections.

http://www.healthleadersmedia.com/leadership/docs-hospitals-insurers-blast-last-ditch-aca-repeal?spMailingID=11982714&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1241926561&spReportId=MTI0MTkyNjU2MQS2#

With one exception, most physician groups stating a position viewed the bill as dangerous.

As momentum builds for the GOP’s latest Obamacare repeal effort, most major physician and hospital groups skewered the proposal.

But some held their tongues or even welcomed certain new “freedoms” the bill could afford.

Last week senators Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.), and Ron Johnson (R-Wis.) introduced a healthcare bill to pool money that would have been funnelled into premium and cost-sharing subsidies and Medicaid expansion and direct it instead to states in the form of block grants.

The proposal would also repeal the Affordable Care Act’s individual and employer mandates, the medical device tax, and “strengthen the ability for states to waive Obamacare regulations,” according to a Sept. 13 press release posted on Cassidy’s website. It appears the bill will have no committee hearings or markups before coming to the Senate floor for a vote.

With one exception, most physician groups stating a position viewed the bill as dangerous.

Physicians: ‘Do No Harm’

The new bill “violates the precept of ‘first do no harm,'” said James Madara, MD, CEO and executive vice president of the American Medical Association, in a letter to Senate Majority Leader Mitch McConnell (R-Ky,) and Minority Leader Chuck Schumer (D-N.Y.).

“Similar to proposals that were considered in the Senate in July, 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,” he wrote.

The AMA is especially concerned about repealing the premium subsidies, cost-sharing reductions, small business tax credits, and Medicaid expansion, and described the Medicaid block grants, which would run through 2026 as “inadequate and temporary.”

“Per-capita caps (a form of block grant) fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation,” he wrote.

Rebecca Parker, MD, president of the American College of Emergency Physicians, also penned a letter to Senate leadership highlighting the dangers her members see in the bill.

“ACEP cannot support any legislation that does not include emergency medical care as a covered benefit in health insurance,” she wrote. “Yet, [the Cassidy-Graham bill] allows states to easily forego requiring insurers to adhere to important consumer protections, including the requirement to cover the ten essential health benefits, and protections for those with pre-existing conditions.”

Ninety-five percent of Americans believe health plans should cover emergency medical care, Parker noted, which is currently one of the ACA’s essential benefits.

“[E]mergency physicians agree with them. Patients can’t choose when and where they will need emergency care, and they shouldn’t be punished financially for having emergencies,” she continued.

And a joint letter from six specialty organizations representing more than 500,000 physicians — the American Academy of Family Physicians, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, the American College of Physicians, and the American Psychiatric Association — described the bill as “disruptive” and “harmful” to patients.

In addition to failing to preserve the coverage and consumer protections enacted by the ACA, the groups said the new bill “would create a health care system built on state-by-state variability that would exacerbate inequities in coverage and most likely place millions of vulnerable individuals at risk of losing their health care coverage.”

The groups continued to urge Congress to pursue “regular order” including hearings, debates, and committee markups and not to rush a vote.

Hospitals Disappointed

Because the new bill’s approach is similar to previous repeal proposal’s, Bruce Siegel, MD, MPH, the president and CEO of America’s Essential Hospitals, said he anticipates a similar result: “millions of Americans losing coverage. ”

“Unlike those previous proposals, the Graham-Cassidy bill provides no meaningful relief from looming cuts to Medicaid disproportionate share hospital (DSH) payments,” he noted, while stressing that the new bill would also limit “how states raise support for the safety net.”

“Rather than providing flexibility, this would limit states’ coverage and financing choices,” he said.

Similarly, “This proposal would erode key protections for patients and consumers and does nothing to stabilize the insurance market now or in the long term,” said Rick Pollack, CEO of the American Hospital Association, in a press statement.

On Board, On the Fence

Not all physicans want to see the bill shredded.

Despite her “mixed feelings,” Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, said on the whole, “I think that it may in the long-term make things a tiny bit better by permitting a wedge of freedom.”

Examples of this freedom include giving block grants to states and rolling back federal regulation so that states can experiment and make their Medicaid programs more efficient.

“The idea that we can just infinitely expand the money that we’re pouring into Medicaid is going to come to a halt. It has to. How can you keep spending money that you don’t have?” Orient asked.

Half of all Medicaid funding is money coming from creditors, because the government has to borrow 50 cents of every dollar it spends, she said.

The American Association of Neurological Surgeons/Congress of Neurological Surgeons indicated that members like giving states more control over how healthcare dollars are spent, and repeal of the medical device tax. But the group is concerned about “backsliding” on other insurance reforms, such as those involving pre-existing conditions, a press representative told MedPage Today in a phone call.

“Without a [Congressional Budget Office] score, it’s impossible to predict what the states are going to do at this point,” the representative said. No CBO analysis of the bill other than its effect on the federal budget is expected.

Other specialty groups have remained silent on the bill.

Insurers Skeptical

Another important set of stakeholders also stated opposition to Graham-Cassidy: the health insurance industry, whose chief trade group declared it “cannot support this proposal.”

Marilyn Tavenner, CEO of America’s Health Insurance Plans, outlined six “guiding principles” in a letter to McConnell and Schumer on Wednesday. They included: stabilizing the individual insurance market, a strong Medicaid program, guaranteed coverage for all, sufficient lead time to implement reforms smoothly, improved affordability, and reliance on the private market.

“The Graham-Cassidy-Heller-Johnson proposal fails to meet these guiding principles,” the letter said, “and would have real consequences on consumers and patients by further destabilizing the individual market; cutting Medicaid; pulling back on protections for pre-existing conditions; not ending taxes on health insurance premiums and benefits; and potentially allowing government-controlled, single payer health care to grow.”

Senate leadership aims to bring the bill to the floor for a vote next week. The body faces a Sept. 30 deadline to pass legislation with budgetary implications without needing 60 votes to overcome a filibuster.

http://www.commonwealthfund.org/publications/blog/2017/sep/potential-effects-of-graham-cassidy

Last week, Sens. Lindsey Graham (R–S.C.) and Bill Cassidy (R–La.) unveiled congressional Republicans’ latest bill to repeal and replace the Affordable Care Act (ACA). The Congressional Budget Office (CBO) has indicated that it will not release a score of the bill that includes its effects on insurance coverage for several weeks, but Senate leaders have indicated they will hold a vote without a score. The bill, however, is similar to prior ACA repeal-and-replace bills for which we do have CBO scores. Based on those estimates, it is likely that the bill, if enacted, would lead to a loss of health insurance for at least 32 million people after 2026.

The bill can be boiled down to five key provisions:

• Repeals the ACA marketplace subsidies and federal funding for the Medicaid expansion in 2020.
• Creates temporary block grants for states that end in 2026. States can use the funds for a wide range of purposes.
• Repeals the individual and employer mandates.
• Creates a waiver program for states that would allow insurers to charge people more based on their health and cut benefits like maternity care.
• Places per capita spending limits on funding for the traditional Medicaid program.

Repeal with Temporary Block Grants. The bill repeals the ACA’s marketplace subsidies and Medicaid expansion, which currently cover about 30 million people. The Center on Budget and Policy Priorities (CBPP) estimates Graham-Cassidy would cut $239 billion from current spending levels, and then divide the remaining funding among states according to a complicated block-grant scheme that results in gains for some states at the expense of deep losses in other states. CBPP projects that the states that would lose the most funding are those that expanded Medicaid, including highly populated states like California and New York.

But all of that grant funding vanishes after 2026. CBO estimated the effects of a repeal of the ACA’s subsidies and Medicaid expansion in January. The bottom line: elimination of those provisions in combination with a repeal of the law’s individual mandate could lead to a loss of health insurance coverage for at least 32 million people. Compounding the coverage losses, Leighton Ku and colleagues at George Washington University have estimated that a repeal of the coverage expansions would have severe nationwide economic effects, leading to a loss of 2.6 million jobs.

Ingredients for Individual Market Instability. While supporters of the Graham-Cassidy bill claim it is market-based, it contains the ingredients for market instability, including the immediate repeal of the penalties for the individual mandate requiring health insurance. CBO’s prior analyses of the elimination of the individual mandate found that 15 million to 18 million people would become uninsured in the first full plan year after enactment (in this case 2019), as people dropped their coverage from all sources and insurers left the marketplaces. CBO also projected that premiums in the individual market would climb by 15 percent to 20 percent in the first plan year. The majority of that increase would come from the repeal of the mandate penalties: insurers would expect that those who remained in the pool would be the least healthy. And as the CBPP has pointed out, uncertainty over how states would use their block-grant funding would likely lead to even greater instability in the individual market.

Graham and Cassidy try to stem these potential market imbalances in two ways. The bill would bring back the temporary premium stabilization funds for insurers featured in both the Senate and House bills, but only for two years. Then it would allow states to apply for waivers that would let insurers charge people with health problems higher premiums, and change other ACA consumer protections such as bans on lifetime benefit limits and comprehensive coverage requirements. CBO’s analyses of a similar waiver in the House-passed American Health Care Act estimated that half the U.S. population could live in states that would likely take up such waivers, shutting out millions of older adults and people with health problems from the individual market, as in the pre-ACA days.

Reaching Beyond the ACA into Medicaid. The Graham-Cassidy bill, like the earlier Senate and House bills, reaches well beyond the ACA and makes the deepest cuts in the Medicaid program since its inception in 1965. Like those prior bills, it places a per-enrollee cap on what the federal government provides to states for their programs. This cap would threaten the health care of an additional 65 million people who depend on the program, including the elderly, disabled, children, pregnant women, and very poor adults. Cindy Mann and colleagues at Manatt Health Solutions estimated that the spending caps in a version of the Senate repeal-and-replace bill earlier this summer would result in federal  spending cuts of $172 billion over 2020 to 2026. And Al Dobson and colleagues found that, under the House-passed bill, the per-capita caps in that bill would result in a loss of $3.6 billion in revenues for safety-net hospitals alone over 10 years. The Graham-Cassidy bill imposes tighter annual limits in later years than both these bills, so losses may exceed these earlier estimates.

A Need for Public Discussion and Bipartisanship on Health Care

By repealing the ACA’s coverage expansions and cutting deeply into the Medicaid program, the Graham-Cassidy bill threatens the health care of as many as 100 million people, from newborns to the elderly. The fundamental purpose of insurance coverage — that it is essential to enabling people in the United States to get timely access to health care — has been sorely missing from this year’s debate over the future of our nation’s health insurance system. This is partly because of the lack of Congressional hearings on the Graham-Cassidy bill and its House and Senate repeal-and-replace predecessors. In stark contrast, the hearings held this month by Sens. Lamar Alexander (R–Tenn.) and Patty Murray (D–Wash.) to inform their search for a bipartisan solution to the ACA’s marketplaces have allowed for a vetting of options and their potential effects. Public discussion and deliberation may not guarantee sound, bipartisan policy solutions, but they at least enable their possibility.

http://www.commonwealthfund.org/publications/blog/2017/sep/graham-cassidy-and-the-states?omnicid=EALERT1276210&mid=henrykotula@yahoo.com

The Graham-Cassidy legislation contains many provisions that are consistent with previous Affordable Care Act (ACA) repeal-and-replace bills. But in its treatment of states and their envisioned role, it departs dramatically from those efforts.

Federal laws often create a flow of federal tax revenue to states to manage programs and services at a local level. Inevitably, some states gain more than others in the process. But Graham-Cassidy does something rare, if not unprecedented: moving funds from one group of states (those that expanded Medicaid) to another (those that did not) (See New York Times graphic). Under any circumstances, this transfer would raise significant questions of fairness. But in this case, there is a special twist. Most of the losers are blue states, most of the winners red. Whether or not the bill’s authors intended this, it creates a precedent that could result in tit-for-tat responses from blue-state legislators in the future. When political winners pillage losers, the savagery of political conflict is bound to increase, and that does not bode well for stable governance of these united states.

Graham-Cassidy’s second departure from past repeal bills is the extensive new authorities it gives states to manage the additional funds made available for health coverage under the Affordable Care Act (ACA). At least through 2026, when ACA-related funding would disappear, the federal dollars associated with Medicaid expansion and subsidies for purchase of individual private insurance would be reduced by an estimated $239 billion, and then be pooled at the federal level and allocated as block grants to each state.

States would have to apply for the use of these funds, but would have much more flexibility than exists under the Affordable Care Act. The bill doesn’t lay out clear federal goals for how the block grants are to be used, and therefore dilutes states’ responsibilities to expand the numbers of insured through stable private health insurance markets. States also can apply for waivers under the grant program to allow participating insurers to vary premiums based on health status, or to offer less comprehensive benefits. Many other requirements of the ACA would disappear — such as the individual and employer mandates. Together, these actions could lead to a loss of coverage for at least 32 million people.

Moreover, state applications for block grants would be due by March 31, 2019, a very short amount of time for states to develop the administrative structure for a state-based coverage expansion program. States that neither ran their marketplaces nor expanded Medicaid under the ACA may not apply at all.

The assertion of states’ prerogatives to control federal funds is a bedrock conservative principle, but there are also strong rationales for federal involvement in the use of such federal outlays. The federal government has a responsibility to ensure that federal taxpayers’ funds are properly used and that services are of acceptable quality and distributed equally among all eligible citizens. For these reasons, joint federal–state control has long been typical of the Medicaid program, and performance requirements accompany many other health grants to states.

There are other rationales for a federal role in health care affairs at the state level. The Commerce Clause of the U.S. Constitution has traditionally recognized the need for federal involvement in economic transactions that affect citizens in multiple states and are important to the national economy. Private health insurance markets often extend beyond state boundaries, as do the networks of providers who care for individuals insured in some states. Thus, intrastate health insurance activities may be subject to the Commerce Clause. Indeed, the strong support by Republicans of the sale of insurance across state lines suggests their desire to increase even further the participation of insurers in interstate commerce.

Virtually all uninsured citizens in the U.S. eventually become Medicare beneficiaries. Research has shown that previously uninsured individuals are much more expensive for Medicare than are the previously insured. Thus, states that choose to use their authority under Graham-Cassidy in ways that increase the numbers of uninsured will be affecting taxpayers in other states.

The correct balance between federal and state prerogatives in extending and regulating health insurance coverage is not straightforward. Graham-Cassidy takes a radical position that departs from precedent. As such, it raises important issues that deserve debate. However, when the bill is brought to the floor next week (as Senate Majority Leader Mitch McConnell has promised), there will be literally no time left under Senate rules for floor debate of the reconciliation legislation to which it will be attached. Nor has there been an opportunity to consider these issues in the extended hearings they deserve.

The proper role of states in ensuring health coverage for their residents has emerged as a core issue in the consideration of this most recent repeal effort. This is a critical issue that will almost certainly not get the attention it deserves.