Senate Leadership Tries To Sweeten Obamacare Replacement Bill To Gain Support

Image courtesy of Mike Silva

The surprise hit show of the summer, “No, Seriously, What The Heck Is Going On With Congress And Healthcare, Though?” is back for the fall season. And in our latest episode, Republican leadership in the Senate is making last-minute changes to the latest Affordable Care Act replacement bill in a targeted effort to win over reluctant GOP lawmakers before their Sept. 30 deadline.

The latest draft [146-page PDF] of the current ACA replacement bill working its way through the Senate is out this morning, and it includes some very specific changes intended to draw support from holdout Senators.

The Bill

Sens. Lindsey Graham (SC), Bill Cassidy (LA), Dean Heller (NV), and Ron Johnson (WI) released the latest proposal to reverse the ACA earlier this month.

They call it the GCHJ Amendment, but everyone else calls it Graham-Cassidy — and it’s not quite a regular bill. It’s technically a budget resolution, which means that it would only need 51 votes to pass the Senate. It also means there is a strict deadline of Sept. 30, when the federal fiscal year ends, for the Senate to okay the bill. After that window closes, it would have to be treated like a traditional piece of legislation and would need a currently-impossible 60 votes to move on to the House.

Additionally, if Graham-Cassidy does pass the Senate by the deadline, the House would not be able to change a single word on it, as that would require the bill going back to the Senate once again for approval. So if the Senate passes this bill, it’s an all or nothing proposition for the House.

The Senate Finance Committee will be holding a hearing on Graham-Cassidy this afternoon (Monday, Sept. 25), and a spokesperson for Senate Majority Leader Mitch McConnell has confirmed that McConnell does indeed intend to bring the proposal to the Senate floor for a vote before the cutoff.

That means anything that happens needs to happen basically within the next five days.

The Problem

The Graham-Cassidy proposal is enormously unpopular — and the speed with which it’s flying through the Senate doesn’t help.

Because of the end-of-month deadline, the non-partisan Congressional Budget Office will not have time to issue a proper score on the bill before the Senate has to vote on it. At best, the CBO can release a high-level report with minimal information about the bill’s potential impact on the deficit — a report that’s expected early this week.

Several independent, non-partisan third-party groups have released first-pass analyses sussing out what the effects of Graham-Cassidy would likely be, however, and all of them find tens of millions of Americans would lose insurance coverage amid massive slashes to Medicaid funding in the majority of states.


It’s not just the general public that opposes the bill, although so far two different polls have both found that, at most, 20-45% of the nation supports Graham-Cassidy, and significant majorities oppose it.

More importantly, though, basically every single stakeholder you can possibly think of has come out in opposition to the bill. That includes groups representing the nation’s schools, doctors, nurses, patients, and hospitals — as well as the groups that represent the health insurance industry.

Most unfortunately for Graham, Cassidy, and Senate Majority Leader Mitch McConnell (KY), the list of people who don’t like the Graham-Cassidy proposal includes an increasing number of Republican Senators.

The Math

The main reason for slamming healthcare reform through as a budget resolution is that doing so means it only needs a simple majority — 51 votes — to pass. (A standard bill is subject to procedural measures that can mean it needs 60 votes in order to pass.)

There are 52 Republican Senators, plus Vice President Mike Pence can cast a tie-breaking 51st vote as needed. That means McConnell can afford to have two members of his party peel off, but not three.

That’s what happened in July, on the last round: Sens. Susan Collins (ME) and Lisa Murkowski (AK) were known “no” votes on the bill, and then Sen. John McCain (AZ) cast a surprise late-night third “no” vote, dooming the proposal.

Late last week, McCain came out as a strong, unequivocal “no” on the proposal, saying, “I cannot in good conscience vote for the Graham-Cassidy bill.”

Sen. Rand Paul (KY) has also been a vocal opponent of the proposal on the grounds that it doesn’t go far enough toward being a true repeal. However, it’s worth noting that he said the same about the July bill, and yet in the end supported it anyway.

Sen. Ted Cruz (TX) announced his opposition over the weekend, saying that the proposal, as it currently stands, does not have his backing and likely does not have the support of his colleague Sen. Mike Lee (UT) either. However, like Paul, Cruz and Lee both opposed the July bill until they didn’t anymore, and cast their votes in favor.

That leaves everyone watching Murkowski and Collins.

Collins has not yet stated formal opposition to the bill, but is considered vanishingly unlikely to end up supporting it. Murkowski, however, has remained an unknown, stating neither support nor opposition on the record.

The Bait

Murkowski and Collins objected to the July bill in large part over its draconian cuts to Medicaid funding and women’s healthcare. The first draft of Graham-Cassidy also put in place massive cuts to Medicaid funding, but not across the board. Rather, some states would benefit, and others would lose out.

Alaska was one of the “loser” states under the original bill, standing to suffer a 38% cut in Medicaid funding under Graham-Cassidy as opposed to the current law. So one of the changes is to sweeten the pot for Alaska specifically, to try and curry Murkowski’s vote.

Other provisions would steer more funding to Arizona and Kentucky, Politico notes — the states represented by McCain and Paul, respectively.

Still more changes are designed to apply to the holdouts from the more conservative side of things — that’d be your Paul, Cruz, and Lee.

Those changes include allowing states to split the sick and the healthy into multiple “risk pools,” which means the cost of obtaining insurance if you have a pre-existing condition (or look like you might develop one) would skyrocket to potentially unattainable levels.

States would also be allowed to decide what the out-of-pocket cap (if any) should be, and how much insurers can charge anyone with a pre-existing condition. Nor would states need to seek formal waivers for these or any other changes, instead simply submitting a plan saying that “adequate and affordable” coverage will be available.

The Kaiser Family Foundation’s Larry Levitt described the update as, “in effect, federal deregulation of the insurance market.

Our colleagues down the hall at Consumers Union agreed. “This bill is an even harsher version of the previous failed proposals that were overwhelmingly rejected by Americans. It is not only a repeal of the Affordable Care Act — threatening key consumer protections and coverage requirements that ensure those with preexisting conditions have access to meaningful care — but also a historic undercutting of the Medicaid program,” said CU’s Betsy Imholz. “No one time buyout, carve out, or ‘fix’ can address these problems.”

The Hearing

If you want to watch today’s Senate Finance Committee hearing on the Graham-Cassidy bill, it will be live-streamed on the Committee’s website beginning at 2 p.m. Eastern.

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