When Republicans in the U.S. Senate fell one vote short in July, it looked like their seven-year bid to undo the Affordable Care Act, aka Obamacare, had failed. Now there’s an effort to see if a different repeal bill, known as Graham-Cassidy, can make it through the Senate before a Sept. 30 deadline. Proponents say it would put reshaping health insurance in the hands of the states. Its detractors call it the same old steep cuts in coverage in a new wrapper. Over the weekend, its sponsors revised the measure to try to win over several holdouts in the face of growing Republican skepticism.
1. What would Graham-Cassidy do?
The proposal by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana would replace Obamacare’s insurance subsidies with lump-sum payouts to states, known as block grants. The states would decide for themselves how to help people get health coverage. The bill, if signed into law, would spell an end to the Obamacare requirements that individuals obtain health insurance, that most employers provide it to their workers, and that insurers can’t deny coverage or charge more to people with pre-existing medical conditions. The proposal would end the Obamacare tax on medical devices while keeping others intact, including taxes on the wealthy, to fund the block grants. Those grants would expire in 2026.
2. How and why was the bill changed?
The new version, which is scheduled to be discussed at a Senate Finance Committee hearing on Monday afternoon, directs additional funding to certain states, including Alaska, an apparent attempt to win the vote of its wavering senator, Lisa Murkowski. The revised bill also changes language regarding people with pre-existing conditions. It would require states to describe how their health plans “shall” provide them with access to affordable coverage. (The original language said each state had to show how it “intends” to provide such coverage.) What hasn’t changed is that the bill still gives states broad new authority to allow insurance companies to provide skimpier plans with far fewer benefits while charging higher premiums to the sick and the old.
3. How is it different from previous repeal attempts?
The Graham-Cassidy bill leaves to the states many questions that other Republican proposals would have had the federal government handle, like setting the size of insurance subsidies. It also strives to equalize Medicaid spending among states, and would cut the program in the mostly Democratic states that expanded it under the ACA, while sending billions to the mostly red states that didn’t.
4. How is it like previous repeal attempts?
In addition to ending Obamacare mandates, it would cap spending on Medicaid, the huge federal program for the poor and disabled.
5. Why does the bill face a deadline?
Republicans hold 52 seats in the 100-member Senate. They want to use a procedure, budget reconciliation, that allows legislation to pass with a simple majority rather than the 60-vote supermajority required to move most bills to a final vote. The Senate’s parliamentarian has ruled that the ability to use reconciliation under the current budget resolution ends when the fiscal year expires on Sept. 30.
6. What has to happen between now and Sept. 30?
Major bills usually aren’t voted on without a score from the Congressional Budget Office, which will assess whether Graham-Cassidy meets the standards for a simple-majority reconciliation measure. The CBO said it will offer a partial assessment of the measure but won’t have estimates of its effects on health insurance coverage or premiums for at least several weeks.The parliamentarian also has to rule on whether any of its provisions aren’t eligible for reconciliation, which is supposed to be limited to tax and spending provisions.
7. What are the bill’s chances?
As of Monday morning, uncertain. Since Democrats have unanimously opposed efforts to repeal the ACA, Republicans need the support of at least 50 of their 52 members. (Vice President Mike Pence, in his role as president of the Senate, would cast the tie-breaking 51st vote.) Senator Rand Paul of Kentucky says he’ll oppose Graham-Cassidy because even it retains too many elements of Obamacare. Senator John McCain of Arizona came out against the bill and called on the Senate to hold hearings and develop a bipartisan bill. Senator Susan Collins of Maine, who opposed the earlier Republican bill because it cut Medicaid spending too deeply, said she’s inclined to vote against Graham-Cassidy. Senator Ted Cruz of Texas said he’d oppose it without significant revisions. And a number of other senators had yet to make their positions known.
8. If it passes the Senate, what would happen in the House?
If the Senate passes Graham-Cassidy, the Republican-controlled House would have a chance to adopt it -- but only word-for-word, unchanged. If House Republicans were to demand changes, they would need the support of 60 senators, which is a near-impossibility. House Speaker Paul Ryan has spoken positively about the bill, as has Republican Representative Mark Meadows, chairman of the conservative House Freedom Caucus. But a significant number of House Republicans come from states that could lose billions in Medicaid money under Graham-Cassidy.
9. Who’s for the bill?
President Donald Trump supports it, though it’s not clear what he’s done beyond tweet his endorsement and attack McCain for opposing it. Many Republicans feel pressure from their base and their donors for failing so far to repeal Obamacare -- a failure Trump has excoriated them for.
10. Who’s against it?
Along with Democrats, several Republican governors in states that expanded Medicaid. Credit ratings agency Fitch Ratings has said that because Medicaid spending represents one-third of state budgets, the bill would pose big challenges for them, particularly those that took advantage of Obamacare’s Medicaid expansion. Doctors’ organizations, hospital associations, insurance industry lobbying groups and an association of state Medicaid directors have all come out against Graham-Cassidy, saying it would disrupt insurance markets.
11. What happens if it fails?
Democrats and Republicans on the Senate’s health committee had been working together to see if they can write a narrow bill to address some of Obamacare’s flaws that threaten to lead to fewer choices and higher premiums for some people who buy individual insurance policies. That effort was put on hold when Graham-Cassidy was introduced.
The Reference Shelf
- QuickTake Q&As on "Medicare for all," the role of the Senate parliamentarian and why insurers are getting antsy about Obamacare.
- A summary of the Graham-Cassidy bill, which is also sponsored by Ron Johnson of Wisconsin and Dean Helller of Nevada, and its full text.
- An analysis by the liberal Center on Budget and Policy Priorities.
- A comparison of Graham-Cassidy and previous repeal bills.