After a dramatic series of failed Senate votes in July, there’s one repeal-and-replace plan for the Affordable Care Act left standing. Trump is pushing for a vote, per Politico, and John McCain has announced his support, but the bill has yet to gain significant traction.
The proposal, crafted by Sens. Bill Cassidy (R-La.), Lindsey O. Graham (R-S.C.) and Dean Heller (R-Nev.), essentially turns control of the health-care markets over to the states. Rather than funding Medicaid and subsidies directly, that money would be put into a block grant that a state could use to develop any health-care system it wants. It also allows states to opt out of many ACA regulations. “If you like Obamacare, you can keep it,” Graham has said, using a common nickname for the health-care law. “If you want to replace it, you can.”
In reality, that may not be true. The Medicaid expansion and subsidy funding would be cut sharply compared to current spending, going to zero in a decade.
“You can’t actually keep the same program if your federal funding is being cut by a third in 2026,” said Aviva Aron-Dine, a senior fellow at the left-leaning Center on Budget and Policy Priorities. And even putting aside the cuts, she said, the block grant structure would fundamentally change the health-care landscape. “[Funding] is capped, so it wouldn’t go up and down with the economy,” when fewer or more people become eligible for subsidies.
Republicans contest this. The drop in funding “gives strong incentives for the states to be more efficient with their program,” said Ed Haislmaier, a senior fellow at the conservative Heritage Foundation. That is, states may be able to maintain the ACA structure and regulations as long as they streamline operations.
If the streamlining turns out to be insufficient, the cuts would hit liberal states the hardest, according to a report by the Center for Budget and Policy Priorities. This is largely because they tend to be the biggest spenders on health care: They’ve expanded Medicaid and aggressively signed people up for marketplace coverage. They have the most to lose.
On the whole, Aron-Dine says, “This is a lot more similar to the [Senate repeal bill] than different. All of them end with devastating cuts to marketplace subsidies, Medicaid, and weakening of consumer protections.”
Haislmaier agreed, pointing out the Cassidy-Graham plan was originally intended as an amendment to the Senate bill.
Here’s the nitty gritty of what would change, compared to the ACA and the Senate plan that failed in July:
Under the Cassidy-Graham plan, the mandates would be eliminated at the federal level. States could choose to keep the measure, replace it or get rid of it completely.
The federal health insurance subsidies that help most people with ACA marketplace plans afford their coverage would change. This bill would shift those subsidies to the state-level, so people in some states may see their subsidy scaled back or eliminated.
The bill would restructure Medicaid and decrease its funding. That would make it very difficult for states to maintain the Medicaid expansion.
The odds are slim, but the White House still hopes for action on a bill drafted by Lindsey Graham and Bill Cassidy.
President Donald Trump and some Senate Republicans are refusing to give up on Obamacare repeal, even after this summer’s spectacular failure and with less than a month before a key deadline.
The president and White House staff have continued to work with Republican Sens. Lindsey Graham of South Carolijna and Bill Cassidy of Louisiana over the summer on their proposal to block grant federal health care funding to the states. And though the bill is being rewritten and Congress faces a brutal September agenda, Trump and his allies on health care are making a last-gasp effort.
“He wants to do it, the president does. He loves the block grants. But we’ve got to have political support outside Washington,” Graham said in an interview. He said the bill needs to have a “majority of the Republican governors behind the idea” to gain momentum in the Senate.
But there’s far more work to do even than that. Senate Majority Leader Mitch McConnell would need to find room on the packed calendar this month to hold another uncertain push to repeal Obamacare on party lines. The Senate has only until the end of the month to pass the measure using powerful budget reconciliation procedures, but is also planning to fund the government, raise the debt ceiling, write a new defense policy bill and extend a host of expiring programs.
Cassidy said he hopes to have the bill text finalized by this week and has declined to reveal details about what changed in the bill during August.
“We are still refining the legislative language — just things you got to clear up,” he said. “We think we have good legislation, good policy.”
The Congressional Budget Office would also still need time to analyze the cost of the bill, a process that could take several weeks.
Trump berated McConnell and the Senate GOP over the summer for falling one vote short of sending repeal into conference with the House in July, when Sen. John McCain of Arizona voted down the GOP’s “skinny” repeal bill. So the White House has continued to work on the Graham-Cassidy bill behind the scenes, seeing it as the best option to make progress, according to several administration officials.
The bill would keep most of Obamacare’s taxes and devolve many spending decisions to the states. It was submitted as an amendment to the repeal bill in July but did not receive a vote; aides say it could not pass the Senate in its current form.
Trump has intermittently told aides he wants progress on health care and is still frustrated that the bill failed. The White House’s legislative team has talked with Republican governors in recent weeks and is planning to bring more to the White House, according to one of the officials. Internally, White House officials say they have listened to concerns from governors and tried to tweak the state block grant formulas.
Hill leadership hasn’t played a central role in the effort.
McConnell said in Kentucky last month that the path forward is “somewhat murky” and pointed to efforts by Sen. Lamar Alexander (R-Tenn.) to stabilize insurance markets as one avenue forward, though he doubted Democrats’ resolve on the bipartisan effort.
“We’re going to see what Sen. Alexander and his team can do on a bipartisan basis. The Democrats have been pretty uninterested in any reforms. They’re really interested in sending money to insurance companies but not very interested in reforms,” McConnell said then.
Inside the White House, there is little hope that a health care bill can happen quickly, with a stacked legislative agenda. And some close to the president prefer he would focus on tax reform and other immediate fiscal issues.
The Senate parliamentarian has ruled that the chamber’s reconciliation instructions, which allow the GOP to evade a Democratic filibuster and the chamber’s 60-vote requirement, expire at the end of the month. Republicans are planning to use their next budget measure to pass tax reform via a simple majority. But Graham insisted there’s a short window to fulfill the party’s seven-year promise if the GOP goes into overdrive, starting this week.
“It’s possible, yes. But you’ve got to do it quickly … introduce it this week, have a hearing soon about the bill, then the process is set to actually take it to floor and vote,” Graham said. “Everything has to fall in place.”
President Donald Trump renewed his call for Senate Republicans to take another crack at dismantling Obamacare, saying Thursday it’s a “disgrace” that they failed to pass a repeal bill.
“They lost by one vote,” Trump said from his Bedminster, New Jersey, golf course. “For a thing like that to happen is a disgrace.”
The president has hectored Senate Republicans for days over their collapsed health care effort, most recently singling out Majority Leader Mitch McConnell for criticism.
“I just want him to get repeal and replace done,” Trump told reporters, when asked about his multi-day string of tweets attacking the Kentucky Republican over health care. “It’s almost two years, and all I hear is repeal and replace. And I get there, and I said where’s the bill? I want to sign it.”
McConnell has suggested that the GOP should move on from health care after falling just short of the 50 votes he needed to pass a “skinny” repeal bill, and instead focus on tax reform. And earlier this week, McConnell said Trump has “excessive expectations” about how quickly Congress can pass legislation.
But Trump demanded that Republicans follow through on their agenda, suggesting further failure could cost McConnell his job atop the Senate GOP.
“If he doesn’t get repeal and replace done, and if he doesn’t get taxes done, meaning cuts and reform, and if he doesn’t get a very easy one to get done, infrastructure, he doesn’t get them done, then you can ask me that question,” Trump said.
Two more Republican senators defected from the revised Better Care Reconciliation Act Monday evening, effectively sinking the ACA repeal and replacement bill, according to The New York Times.
Here are five things to know about the bill’s collapse.
1. The two defectors were Republican Sens. Mike Lee of Utah and Jerry Moran of Kansas. Both are Tea Party senators who opposed the ACA, so their defections came as a surprise, according to Bloomberg. Mr. Moran said in a statement he opposed the BCRA because it “fails to repeal the ACA or address healthcare’s rising costs.” He added, “We should not put our stamp of approval on a bad policy.” Mr. Lee did not support the bill because it did not repeal all of the ACA’s taxes or lower premiums enough for the middle class, according to a statement.
2. Without the support of Mr. Lee and Mr. Moran, the bill is dead. Senate Republicans needed at least 50 votes to pass the bill via reconciliation. They hold 52 seats, but two Republicans already announced their opposition: Sens. Susan Collins of Maine and Rand Paul of Kentucky. “Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful,” Senate Majority Leader Mitch McConnell, R-Ky., said in a statement.
3. Mr. McConnell now wants to return to the full ACA repeal strategy. To do this, the Senate would take up the House bill, the American Health Care Act, and tack on an amendment to repeal the 2010 healthcare law, according to Mr. McConnell’s statement. This would repeal the ACA after a two-year delay to allow for Congress to facilitate a transition and a potential replacement. A bill similar to this was passed in 2015, but was repealed by former President Barack Obama.
4. Despite support in 2015, the straight repeal strategy will be tough to pass now. The New York Times report said this strategy “has almost no chance to pass,” because it will destabilize insurance markets too much. An analysis from the Congressional Budget Office published in January found 32 million more people would be uninsured by 2026 under the 2015 repeal bill. This would set back insurance rates more than the BCRA or the AHCA, which were estimated to increase the number of uninsured by 22 millionand 23 million by 2026, respectively.
5. President Donald Trump is pushing Congress toward the full repeal. He tweeted Monday night, “Republicans should just REPEAL failing Obamacare now & work on a new healthcare plan that will start from a clean slate. Dems will join in!”