If you transport yourself back to the summer, there were two issues on which a critical mass of Republican senators were unwilling to bend: They refused to back deep cuts to Medicaid, at least not without a softer landing and a viable alternative for covering the program’s current beneficiaries than the GOP’s bills provided; and they would not roll back Obamacare’s protections for people with preexisting conditions.
Graham-Cassidy, when you cut through the spin, would do both.
The bill ends Obamacare’s Medicaid expansion in 2020, with no “glide path” that Republican senators like Ohio’s Rob Portman and West Virginia’s Shelley Moore Capito previously demanded. It ends the expanded eligibility for Medicaid that Obamacare created, and even if states tried to reconstruct Medicaid expansion on their own with the bill’s block grant, there almost certainly would not be enough money without an impractical infusion of state dollars.
On top of that, the bill fundamentally overhauls Medicaid by placing a federal spending cap on the program. The Medicaid spending caps alone would cut the program’s spending by $120 billion, versus current law, by 2026, according to Avalere Health, an independent consulting firm.
For much of the debate, those Medicaid cuts and the end of Medicaid expansion were a nonstarter for many Republicans. That’s what Sen. Dean Heller (R-NV) said earlier this year, as he stood besides Nevada Gov. Brian Sandoval and said he couldn’t support a bill that Sandoval opposed.
“This is all about Medicaid expansion,” Heller said, adding: “It’s going to be very difficult to get me to a yes.”
He is now a co-sponsor of Graham-Cassidy, even though Sandoval opposes it.
Sen. Lisa Murkowski (R-AK), one of the most closely watched swing votes yet to take a public position on Graham-Cassidy, suggested to me in June that she couldn’t support any bill that ended Medicaid expansion.
“I want greater access and lower costs,” she told me then. “For instance, if you are going to eliminate Medicaid expansion or even if you’re going to wind down Medicaid expansion, that’s not increasing access.”
As for preexisting conditions, Graham-Cassidy falls short of Republican promises on that issue as well. If states choose to allow it, insurers could once again charge people higher premiums based on their medical history, a practice Obamacare had outlawed.
Cassidy has sought to defend the provision. “The protection is the same,” he told CNN this week.
His justification is that the bill requires states, if they seek a waiver from the Obamacare regulation, to describe how they would maintain “adequate and affordable” coverage for people adversely affected by the change.
The problem is, as Vox’s Sarah Kliff already documented, that the bill isn’t really specific about what those standards actually mean. So it does introduce a degree of uncertainty around how well people with preexisting conditions are protected that the current health care law does not.
“You could stretch the definition pretty broadly of what counts,” Chris Sloan, who has reviewed Graham-Cassidy for Avalere, told Kliff. “Maybe you fund a high-risk pool that only allows in some number of people, and that counts. It’s a pretty wide space.”
Here, again, Republican senators had long pledged they wouldn’t touch the protections for preexisting conditions.
“We’re not going to do anything to change the current law when it comes to pre-existing conditions, I know which was a big concern with the House bill,” Sen. John Cornyn, the No. 2 Republican, said this summer, per the Hill.
That position was supposed to be prevalent throughout the Republican conference.
“I think people understand that’s got to be protected, and people understand what happened when the House dealt with it and opened it up, and it’s just not something that senators are wishing to do,” Sen. Bob Corker (R-TN) said a few months ago.
Axios’s Sam Baker flagged some other provisions — notably, additional funding to address the opioid crisis — that senators had previously conditioned their support on but aren’t included in Graham-Cassidy.
Lastly, there were the process complaints. No Senate health care bill has gone through the regular order of committee hearings, expert testimony, or markups. The Finance Committee hastily scheduled a hearing for next week, but it was a naked attempt to assuage those concerns from a few key senators rather than an earnest start to the normal legislative process.
The most prominent critic of the process, Sen. John McCain (R-AZ), who has urged Republicans to return to regular order since he helped sink Obamacare repeal in July, seemed to see through the gambit.
The nonpartisan Congressional Budget Office has said it will be unlikely to provide estimates on how many people would have health coverage under the bill or what would happen to premiums, because of the tight timeline. Johnson, who was at one time fixated on having enough information to determine his vote, dismissed the CBO analysis as “a detail.”