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September 20, 2017

10 bipartisan governors declare opposition to Cassidy-Graham—but 15 GOP governors come out in support

Daily Briefing

Correction: An earlier version of this story incorrectly stated the Cassidy-Graham bill's effect on the traditional Medicaid program.

A Senate GOP a bill (HR 1628) that would repeal parts of the Affordable Care Act (ACA) gained new support and opposition Tuesday, but many Republican senators remain undecided.

The bill—introduced last week by Republican Sens. Lindsey Graham (S.C.), Bill Cassidy (La.), Dean Heller (Nev.), and Ron Johnson (Wis.)—has been portrayed as the last option for GOP lawmakers to fulfill their promise to repeal the ACA. GOP Senators face a Sept. 30 deadline to pass the bill on a simple majority vote under the budget reconciliation process.

In a state of reform: Profiles of innovative state-level Medicaid transformation

The measure would repeal the ACA's individual and employer mandates retroactively to 2016, as well as the law's taxes on non-qualified spending from health savings accounts (HSAs), medical devices, and over-the-counter medications. Like the Senate's Better Care Reconciliation Act, the Cassidy-Graham bill would reform the Medicaid program by shifting its funding structure to a per capita cap system. The bill also would put in place a new state block grant system for providing coverage to low-income individuals.

A key detail for lawmakers and governors is how the proposal would affect state funding levels. According to Washington Times' "PowerPost," the bill's complex formula has made it difficult for state officials and health care analysts to accurately predict the amount states would receive—though early estimates suggests states that expanded Medicaid under the ACA and have more active beneficiaries could see significant cuts.


The Congressional Budget Office on Monday said a full score on the bill's potential effects will not be ready before the Sept. 30 vote deadline.


A bipartisan group of 10 governors on Tuesday sent a letter to Senate leaders urging them not to consider the Cassidy-Graham bill, and to instead pursue the Senate Health, Education, Labor, and Pensions (HELP) Committee's bipartisan effort to stabilize the exchanges. They wrote, "Legislation should receive consideration under regular order, including hearings in health committees and input from the appropriate health-related parties."

The letter was signed by:

  • Alaska Gov. Bill Walker (I), who holds some sway over Murkowski, a potentially decisive vote who opposed a previous Republican effort to repeal and replace the ACA;
  • Colorado Gov. John Hickenlooper (D);
  • Louisiana Gov. John Bel Edwards (D);
  • Ohio Gov. John Kasich (R)
  • Massachusetts Gov. Charles Baker (R);
  • Montana Gov. Steve Bullock (D);
  • Nevada Gov. Brian Sandoval (R);
  • Pennsylvania Gov. Tom Wolf (D);
  • Vermont Gov. Phil Scott (R); and
  • Virginia Gov. Terry McAuliffe (D).

Separately, Maryland Gov. Larry Hogan (R) on Tuesday announced his opposition to the bill, saying, "Unfortunately, the Graham-Cassidy bill is not a solution that works for Maryland," adding, "It will cost our state over $2 billion annually while directly jeopardizing the health care of our citizens."

According to the New York Times, New Hampshire Gov. Chris Sununu (R) had criticized the bill on Monday.

Several major industry groups also spoke out against the bill Tuesday, as did AARP.

American Medical Association Chief Executive James Madara in a letter to Senate leaders wrote, "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."

American Hospital Association President Richard Pollack said the bill "would erode key protections for patients and consumers."

Federation of American Hospitals President and CEO Chip Kahnon Wednesday said the bill "could disrupt access to health care for millions of the more than 70 million Americans who depend on Medicaid and the marketplaces for their health coverage," adding, "We urge the Senate to reject legislation that fails to move us forward in assuring Americans access to affordable health care and coverage."

The two main insurance industry associations as of Tuesday had not commented on the proposal. But Centene CEO Michael Neidorff said, "From a public policy standpoint, it is not a good piece of legislation," and he urged lawmakers to work together on a bipartisan bill.


Shortly after the opposing governors published their letter, Cassidy released a letter of support from 15 Republican governors, including:


  • Wisconsin Gov. Scott Walker (R);
  • Arkansas Gov. Asa Hutchinson (R);
  • Indiana Gov. Eric Holcomb (R);
  • Iowa Gov. Kim Reynolds (R);
  • Kansas Gov. Sam Brownback (R);
  • Kentucky Gov. Matt Bevin (R);
  • Maine Gov. Paul R. LePage (R);
  • Mississippi Gov. Phil Bryant (R);
  • Missouri Gov. Eric Greitens (R);
  • Nebraska Gov. Pete Ricketts (R);
  • North Dakota Gov. Doug Burgum (R);
  • Oklahoma Gov. Mary Fallin (R);
  • South Dakota Gov. Dennis Daugaard (R);
  • Tennessee Gov. Bill Haslam (R);
  • Utah Gov. Gary H. Herbert (R).

The letter stated, "Adequately funded, flexible block grants to the states are the last, best hope to finally repeal and replace Obamacare—a program which is collapsing before our very eyes. We stand ready to work with you and the other members of the Senate, the Speaker and the other members of the House, and with the President and his administration to repeal Obamacare and replace it with something that works—in the states."

Separately on Tuesday, Arizona Gov. Doug Ducey (R) came out in favor of the bill.

The bill also appears to be getting a push from the White House. Vice President Mike Pence on Tuesday attended the weekly Senate Republican policy luncheon. Pence told reporters of the meeting, "My message today is I want to make sure that members of the Senate know the president and our entire administration supports Graham-Cassidy."

Senate Majority Leader Mitch McConnell (R-Ky.) also appeared to support the bill, which he said "has a great deal of support." However, McConnell has declined to commit to bringing it to the Senate floor for consideration. "We're in the process of discussing all of this. Everybody knows that the opportunity expires at the end of the month," McConnell said.


Many GOP lawmakers remain undecided

While governors are publicly stating where they fall on the bill, several key Republicans—including Sens. Susan Collins (Maine), John McCain (Ariz.), and Lisa Murkowski (Alaska), who all voted against the Senate GOP's final repeal bill in July—said they are still reviewing the bill.

So far, only one GOP senator—Sen. Rand Paul (R-Ky.)—has said that he will vote against the bill. Senate Minority Leader Charles Schumer (D-N.Y.) said Tuesday he is confident no Democrat would vote for the bill, meaning Senate GOP leader could afford to lose only one more vote.

Lawmakers are expected to discuss the bill in more depth during a Senate Finance Committee hearing Monday.

Bipartisan effort on the back burner

Despite some governors and industry stakeholders calling for a bipartisan bill to improve the ACA's exchanges, Senate HELP Committee Chair Lamar Alexander (R-Tenn.) on Tuesday suggested the two parties would not be able to reach an agreement.

In a statement, Alexander said, "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" (Sullivan et al., "PowerPost," Washington Post, 9/19; Levey et al., Los Angeles Times, 9/19; Cornwell, Reuters, 9/19; Min Kim, Politico, 9/19; AP/Sacramento Bee, 9/19; Portnoy, Washington Post, 9/19; Pear/Kaplan, New York Times, 9/19).

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