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How the Graham-Cassidy bill compares to past Republican health care repeal efforts

BananaStock/Thinkstock
BananaStock/Thinkstock

(WASHINGTON) — The clock is ticking for Senate Republicans to be able to repeal and replace Obamacare, following through on their almost seven-year campaign promise, through a special process that requires fewer votes. The deadline to pass the bill with a simple majority of 51 votes is Sept. 30.

For Republicans who worked around the clock in July to try to pass a repeal of the Affordable Care Act (ACA), also called Obamacare, it’s déjà vu. Sen. John McCain, R-Ariz.; Sen. Susan Collins, R-Maine; and Sen. Lisa Murkowski, R-Alaska, are on the fence once more about supporting the GOP’s latest health care proposal.

This time, those Republicans are considering a very different option with the Graham-Cassidy bill, a repeal effort led by Sen. Lindsey Graham, R-S.C., and Sen. Bill Cassidy, R-La.

What’s new, old and controversial about the Graham-Cassidy bill?

Similar to previous Republican repeal efforts, Graham-Cassidy immediately removes the individual and employer mandates to sign up for health insurance, two tax penalties tied to the ACA that continue to be unpopular with the public.

Graham-Cassidy also repeals the medical device tax, which some said was prohibitive to medical innovations. The plan repeals Medicaid funding for Planned Parenthood for one year — just as the ‘skinny repeal’ was designed to do and would increase the amount of money that people can put into health savings accounts, or HSAs, that are popular with Republicans, and consumers could also use that savings money to pay health insurance premiums.

Like past repeal efforts, health insurance premiums for older and disabled Americans would go up with cuts to Medicaid expansion; Medicare would not be changed; and the bill would repeal cost-sharing subsidies in 2020, which give discounts for deductibles and copayments.

What’s different?

The Graham-Cassidy bill would give states more discretion with health care funds. The tax credits, Obamacare-era subsidies and Medicaid expansion dollars would be eliminated. Instead, states would receive block grants of money to allocate as they determine. How much money each state would receive depends on a complicated formula that factors in population size and resident wages, and states would not have to spend money to increase health insurance coverage. Graham-Cassidy block grants would expire in 2026.

“It takes money that previously would have gone to premium tax credits and the Medicaid expansion and divides that up to states in a block grant, but the total amount of funding in those block grants is significantly below what would have gone through Medicaid expansion and tax credits under current law,” said Matthew Fiedler, a fellow with the Center for Health Policy in Brookings’ Economic Studies Program.

“I think, with these block grants, there is going to be such intense uncertainty about what different states are going to do that insurers are going to get nervous and may hedge their bets even before 2020, maybe deciding the market is not worth it,” he said.

The bill also caps Medicaid enrollment and funding, which could affect more than 60 million people. The plan would also allow people over the age of 30 to sign up for catastrophic coverage plans that are high-deductible, low-premium plans in hopes that more healthy, young people will be covered.

Private market rules will remain the same, but states would be allowed to waive rating rules based on health status ratings and age. States would also be allowed to require working as a condition for Medicaid eligibility.

What parts of the Republicans’ bill are controversial?

Because Graham-Cassidy’s block grant plan redistributes Medicaid funding, some states that applied for Medicaid expansion under Obamacare — including some red states — are concerned their residents will lose out those funds and be saddled with very steep bills.

“If Graham Cassidy passes, states will have less than two years to come up with a whole new health insurance program from scratch. And that will be a challenge even for the largest and best-resourced states,” said Larry Levitt, senior vice president at the nonpartisan Kaiser Family Foundation.

While insurers are still required by law to provide health insurance coverage to everyone, Graham-Cassidy would allow states to use waivers to get rid of protections for people with pre-existing conditions, and states can also obtain waivers under Graham-Cassidy to get rid of required coverage for essential health benefits such as maternity care, which could mean higher premiums for sick people.

But a major sticking point for lawmakers has been the rushed process to vote on the bill. Without a full report from the Congressional Budget Office, lawmakers won’t know how much the bill will cost the government or how many people could potentially lose their coverage.

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