September 26, 2017

GOP abandons planned vote on Graham-Cassidy

Daily Briefing

Senate GOP leaders during a lunch Tuesday decided they will not hold a vote this week on a revised bill to repeal and replace large portions of the Affordable Care Act (ACA) and overhaul Medicaid, according to GOP senators and aides.

The news comes after an eventful day Monday in the health reform debate. More than 100 protesters had to be escorted out of a hearing on the so-called "Graham-Cassidy bill" (HR 1628) on Monday. Meanwhile, the Congressional Budget Office (CBO) released a preliminary score that predicted the bill would leave "millions" of U.S. residents without comprehensive health coverage. Shortly after the CBO score was released, Sen. Susan Collins (R-Maine) joined GOP Sens. John McCain (Ariz.) and Rand Paul (Ky.) in opposing the measure.

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

Hearing details

The Senate Finance Committee's hearing Monday afternoon on an updated version of the Graham-Cassidy bill was temporarily adjourned to allow police officers to remove more than 100 protesters, the Washington Post's "PowerPost" reports. During the hearing, protesters chanted, "No cuts to Medicaid. Save our liberty!"

After the lawmakers reconvened, Graham and Cassidy described their changes to the bill, with Graham framing their revisions as "just correcting drafting errors." Cassidy suggested that the lawmakers would not make further changes to the bill, Politico reports.

However, the revised language left many legal and health care experts uncertain about both whether HHS would have the authority to deny state waiver applications and whether states would be able to waive ACA provisions that prohibit insurers from charging higher premiums to individuals with pre-existing conditions.

Cassidy told panel members that under the revised bill, HHS would be able to take actions against states that do not protect individuals with pre-existing conditions, by either denying an application to waive the insurance regulations or reducing federal funding for state's that ultimately do not comply with the bill's rules. However, Matt Fiedler of the Brookings Institution said those "enforcement tools are fairly weak."

CBO, S&P weigh in on revised bill

Meanwhile, CBO released a rush analysis of the Graham-Cassidy bill, which estimated total federal Medicaid spending under the bill would fall by about $1 trillion from 2017 to 2026, compared with current law.

CBO said it did not have time to provide specific projections on how the bill would affect the uninsured rate. It predicted, however, that the revised bill would leave "millions" of U.S. residents without comprehensive health coverage, both because the bill would repeal the ACA's individual mandate and because it would cut federal Medicaid funding and subsidies that help individuals afford private coverage.

Overall, CBO said the revised bill would reduce the federal deficit by at least $133 billion. "Those savings would occur mainly because, under the legislation, outlays from new block grants between 2020 and 2026 would be smaller than the reduction in net federal subsidies for health insurance. Funding would shift away from states that expanded eligibility for Medicaid under the ACA and toward states that did not," the report stated.

A separate report from Standard & Poor's Global Ratings also found the bill would reduce coverage levels, particularly for those between 133 percent and 400 percent of the federal poverty line. If the bill were signed into law, Standard & Poor's also estimated the economy would face a $240 billion loss by 2027 and that 580,000 jobs could be affected.

Collins makes the third no

But the day's most significant development came when Collins joined McCain and Paul in opposing the bill, leaving the measure without sufficient support to pass. 

Collins said both the earlier and newer versions of the bill "open the door for states to weaken protections for people with pre-existing conditions, such as asthma, cancer, heart disease, arthritis and diabetes." She also raised concerns about the process, saying, "The fact that a new version of this bill was released the very week we are supposed to vote compounds the problem."

Even as Collins announced her opposition, Paul opened the door to changing his vote if there were significant changes, saying Monday he would favor the bill if it were revised to eliminate the ACA-funded state block grants. McCain, however, appeared to be a hard "no," as he said he disagrees with the process being used to pass an ACA repeal bill.

According to Axios' "Vitals," Sen. Ted Cruz's (R-Texas) staff also said the senator is currently against the bill, but said he wants "to get to yes."

During a CNN debate on health care Monday night, Graham suggested the Senate GOP would "press on" with the vote this week, saying, "It's OK to vote. It's OK to fall short, if you do, for an idea you believe in."

Where health reform goes from here

GOP Senators face a Sept. 30 deadline to pass a health reform bill on a simple majority vote under the FY 2017 budget reconciliation process. 

Some observers have said Senate GOP leaders could try to restart talks around a bipartisan proposal. BuSen. Lamar Alexander (R-Tenn.), who spearheaded an earlier bipartisan effort, said those talks stopped last week.

Another way the GOP could keep their repeal hopes alive, the New York Times reports, would be to include language in the 2018 fiscal year budget reconciliation bill allowing an ACA repeal bill to pass without a filibuster. The GOP is hoping, however, to use a 2018 reconciliation measure to overhaul the U.S. tax code, and that effort could be complicated if it were intermingled with an ACA repeal push (Reuters/St. Louis Dispatch, 9/25; Frieden, MedPage Today, 9/25; Diamond, "Pulse," Politico, 9/26; Armour/Peterson, Wall Street Journal, 9/25; Kaplan/Pear, New York Times, 9/25; Sullivan et al., "PowerPost," Washington Post, 9/25; Scott, Vox, 9/25; Cancryn, Politico, 9/25; Hellmann, The Hill, 9/25; Baker, "Vitals," Axios, 9/26; Min Kim et al, Politico, 9/26).

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