The Health 202: Here’s how Cassidy and Graham rejiggered their Obamacare overhaul – Washington Post

THE PROGNOSIS

Sen. Bill Cassidy (R-La.). (AP Photo/Alex Brandon)

This morning, Sens. Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) will serve up a new version of their bill overhauling Obamacare, even as the whole grand effort appears headed for a meltdown. The new version still kind of looks the same as the old one. But it apportions bigger slices of federal health spending to the states of key senators who were leaning against — or outright opposed — to the original bill, endangering its success.

If you read the updated bill, which was leaked Sunday night to The Washington Post and other news outlets, it’s pretty clear which senators Cassidy and Graham are playing to. A state-by-state summary claims Alaska would get 3 percent more funding, Arizona would get 15 percent more funding and Maine would get 43 percent more funding from 2020 and 2026 compared to current law.

Senators from all three of those states – Lisa Murkowski, John McCain and Susan Collins – had backed away from the bill in recent days. McCain indicated on Friday he’d oppose the bill because it wasn’t going through regular order, while Collins and Murkowski said they want to better understand how it would affect their own states.

With Sen. Rand Paul (R-Ky.) still insisting he won’t back the bill, nabbing two of those three senators is crucial. Senate Republicans have just five days left to pass a measure repealing and replacing big parts of the Affordable Care Act. Their opportunity runs out on Oct. 1, when the budget reconciliation bill around which they’d based their entire strategy expires.

Acutely aware of the stakes, Senate GOP leadership and the White House are engaged in an all-in effort to rally the votes. But it’s far from clear that they can get all but two Republicans to swallow this latest Cassidy-Graham iteration.

Senator Lisa Murkowski (R-Alaska) speaks to reporters earlier this month. REUTERS/Joshua Roberts

The plan was distributed among Republicans late Sunday. Aides to Murkowski and Collins did not immediately comment. Some Republicans close to the process have long counted Collins as an eventual “no,” predicting that little could be done to the bill to change her mind. On Sunday night, some were once again privately pessimistic the changes would convince her to vote yes. 

McCain is unlikely to bite. Even if the Senate Finance Committee considers Cassidy-Graham 2.0 in its high-profile health-care hearing this afternoon, there wouldn’t be nearly enough time for the Congressional Budget Office to score it before a vote this week. Lawmakers do expect an analysis from the CBO today, but it will be based on the first version of Cassidy-Graham. And that’s a far cry from the “regular order” McCain has called for.

But Cassidy and Graham, who have argued that Republicans must pass a bill repealing much of the Affordable Care Act or face serious retribution from their core voters in next year’s midterms, are pressing forward. They will present their new bill as more equally distributing federal health-care spending among the states, so that no one state faces a big funding cliff.

The duo is still taking the same basic approach to revamping the ACA: The bill gathers its subsidies for private coverage and its Medicaid expansion, lumps together all of that spending, cuts it somewhat, and redistributes it to states in the form of block grants.

Under the first Cassidy-Graham bill, that would have resulted in a median change of 11 percent less funding for states that expanded Medicaid and 12 percent more for states that didn’t, according to an analysis by the nonpartisan Kaiser Family Foundation. But there was a wide variation in the block grant funding; Mississippi would get 148 percent more relative to current law, while New York would get 35 percent less from the federal government, Kaiser had estimated.

The new version doesn’t change the total sum of money the federal government would spend on the block grants from 2020 to 2026. Instead, it tries to smooth out the formula in what its sponsors hope is an effort to put states on a more equal footing. But the new version also creates some winners and losers: South Dakota would see the largest funding increase (88 percent) while Oregon would lose the most federal funding (17 percent).

–Let’s look at Alaska and Maine. Kaiser had estimated the first version of Cassidy-Graham would result in 8 percent less block grant funding for Alaska; Republicans claim that under their latest bill Alaska would get 3 percent more. Kaiser had also estimated that Maine would get 8 percent more under the initial measure; it would get 43 percent more under the revised version of the bill, according to the GOP documents.

But let’s also throw in an important caveat here: The estimates that Cassidy and Graham will publicly release today make some assumptions that independent analysts say are rather disingenuous.

For one thing, the state funding estimates don’t take into consideration the bill’s additional cuts to regular Medicaid spending. If those cuts were considered, it would be clear that states like Alaska and West Virginia would still be losing out on federal funds overall. And the GOP estimates also assume that states would slash their own funding for coverage and then factor that into the final number as “state savings.”

Of course, opponents of Cassidy-Graham noted these things — and kept sharply criticizing the bill overall — last night and into the early morning hours. Reporters also pointed out how the Republican estimates could be misleading:

From the Wall Street Journal’s Michelle Hackman: 

The Graham-Cassidy state-by-state numbers folks are citing tonight
1) were produced by HHS
2) do not factor in significant medicaid cuts

— Michelle Hackman (@MHackman) September 25, 2017

From the Center on Budget and Policy Priorities’s Jason Leibenluft:

Seriously, folks: these #’s floating around don’t even include the cap to Medicaid program (was $1 trillion cut from ’20-’36 in prior draft)

— Jacob Leibenluft (@jleibenluft) September 25, 2017

Will this latest Obamacare repeal recipe rise – or burn again? Keep your eyes on the oven.

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AHH, OOF and OUCH

Sen. Ted Cruz (R-Tex.). (AP Photo/Manuel Balce Ceneta, File)

AHH: The new Cassidy-Graham bill also makes a play for the votes of Sens. Ted Cruz of Texas and Mike Lee of Utah by giving states more ability to duck federal insurance regulations. States could potentially lift existing caps on out-of-pocket costs, allowing insurers to offer leaner insurance policies that appeal to healthier consumers who want lower monthly premiums.

However, the Senate parliamentarian may rule that lifting ACA regulations in this manner isn’t closely enough tied to federal health spending to go in the budget reconciliation vehicle Republicans are using.

Furthermore, many are skeptical that someone like Cruz, who has made repealing Obamacare a key part of his entire Senate term, would be the vote to sink the whole thing. But Cruz made a threat in that direction yesterday, when he said at the Texas Tribune Festival that Cassidy and Graham don’t have his vote, or Lee’s either.

From Houston Chronicle reporter Jeremy Wallace:

Ted Cruz on Graham-Cassidy: “right now they don’t have my vote” #TribFest17pic.twitter.com/mzsNmfpTs7

— Jeremy Wallace (@JeremySWallace) September 24, 2017

From Politico’s Seung Min Kim: 

Despite Cruz saying today he thinks Lee opposes Graham-Cassidy, Lee spox says nothing has changed, hasn’t committed one way or another

— Seung Min Kim (@seungminkim) September 24, 2017

HuffPost reporter Jonathan Cohn:

Translation: Don’t count on Cruz to kill the bill https://t.co/7sxNuLzpZ8

— Jonathan Cohn (@CitizenCohn) September 24, 2017

From The Post’s Dave Weigel: 

If Cruz/Rand/Lee start making more demands/changes to Cassidy-Graham, it transforms back into the bills that couldn’t pass in July.

— Dave Weigel (@daveweigel) September 24, 2017

From The Daily Beast’s Sam Stein: 

some $ for Alaska. Some market segmentation and loosening of regulation for Cruz/Lee/Rand. and maybe, just maybe, you get to 50.

— Sam Stein (@samstein) September 25, 2017

OOF: In a popularity contest with Obamacare, the Cassidy-Graham health-care bill would lose, big time. That’s according to a Washington Post-ABC News poll released Friday finding that roughly twice as many people strongly prefer current law to the GOP plan, 42 to 22 percent.

These aren’t necessarily gut reflexes, either, because the poll described three aspects of Cassidy-Graham to voters before asking what they prefer: its elimination of the requirement for nearly all Americans to have health insurance, the phasing out of federal funds to help lower- and moderate-income people buy health insurance, and letting states replace federal rules on health coverage with their own rules.

A few more takeaways from the poll:

–Fifty-six percent of respondents said they prefer the Affordable Care Act to Cassidy-Graham; 33 percent said they prefer Cassidy-Graham over the ACA.

–There’s a strong partisan divide; 85 percent of Democrats said they prefer the ACA to the GOP plan; 66 percent of Republicans said they prefer the GOP plan.

–Among independents, 54 percent said they prefer the ACA while 35 percent said they prefer Cassidy-Graham.

OUCH: Last night, President Trump left open the possibility that Cassidy-Graham might not be successful despite likely plans to vote on it this week (McConnell folks have said Wednesday is the target), my colleague Abby Phillip reports.

“Eventually we’ll win, whether it’s now or later,” Trump said as he prepared to board Air Force One to return to Washington after spending the weekend at his golf resort in Bedminster, N.J.

Trump lamented that Republicans still have reservations on health-care even though the bill “happens to be particularly good” for their states.

“I’ve been watching for seven years as the Republicans have been saying repeal and replace,” he said. “My primary focus, I must tell you — and has been from the beginning as you can imagine — is taxes…I believe we will be successful in the largest tax cut in our country’s history.”

TRUMP TEMPERATURE

President Trump in Huntsville, Ala. (AP Photo/Brynn Anderson)

Trump had a lot to say about health-care over the weekend. He’s pouring on the pressure left and right:

John McCain never had any intention of voting for this Bill, which his Governor loves. He campaigned on Repeal & Replace. Let Arizona down!

— Donald J. Trump (@realDonaldTrump) September 23, 2017

Arizona had a 116% increase in ObamaCare premiums last year, with deductibles very high. Chuck Schumer sold John McCain a bill of goods. Sad

— Donald J. Trump (@realDonaldTrump) September 23, 2017

Large Block Grants to States is a good thing to do. Better control & management. Great for Arizona. McCain let his best friend L.G. down!

— Donald J. Trump (@realDonaldTrump) September 23, 2017

I know Rand Paul and I think he may find a way to get there for the good of the Party!

— Donald J. Trump (@realDonaldTrump) September 23, 2017

Alaska had a 200% plus increase in premiums under ObamaCare, worst in the country. Deductibles high, people angry! Lisa M comes through.

— Donald J. Trump (@realDonaldTrump) September 23, 2017

Democrats are laughingly saying that McCain had a “moment of courage.” Tell that to the people of Arizona who were deceived. 116% increase!

— Donald J. Trump (@realDonaldTrump) September 23, 2017

Alaska, Arizona, Maine and Kentucky are big winners in the Healthcare proposal. 7 years of Repeal & Replace and some Senators not there.

— Donald J. Trump (@realDonaldTrump) September 24, 2017

HEALTH ON THE HILL

Sen. John McCain (R-Ariz.) was one of several Senate Republicans to express opposition to the GOP health-care bill over the weekend. (Photo by Melina Mara/The Washington Post)

–Republican senators appeared to topple like dominoes over the weekend, before details of the revised Cassidy-Graham bill leaked out. First, McCain blasted out a news release on Friday saying he’d consider supporting legislation had it undergone extensive hearings, debate and amendments — but noting that it hasn’t.

“As I have repeatedly stressed, health care reform legislation ought to be the product of regular order in the Senate…instead, the specter of September 30th budget reconciliation deadline has hung over this entire process,” McCain’s release said. “We should not be content to pass health care legislation on a party-line basis, as Democrats did when they rammed Obamacare through Congress in 2009.”

McCain said he’d much prefer the bipartisan effort that Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) (the Republican and Democratic leaders of the Health, Education, Labor and Pensions Committee, respectively) were pursuing to stabilize the ACA marketplaces next year. That effort appeared to fall by the wayside last week as Republican leadership tried to create momentum for Cassidy-Graham.

“I fear that the prospect of one last attempt at a strictly Republican bill has left the impression that their efforts cannot succeed,” McCain said. “I hope they will resume their work should this last attempt at a partisan solution fail.”

Sen. Susan Collins (R-Maine) (AP Photo/Robert F. Bukaty, File)

A defection by McCain makes passing Cassidy-Graham basically impossible without help from either Collins or Paul. And both those senators backed away during the Sunday morning talk shows. Collins told CNN she’s worried about how the GOP bill would affect Medicaid recipients and people with preexisting medical conditions.

“It is very difficult for me to envision a scenario where I would end up voting for this bill,” Collins said. “I have a number of serious reservations about it.”

Collins said she had a lengthy discussion with Vice President Pence on Saturday, but wants to see an analysis of the legislation from the nonpartisan Congressional Budget Office this week before she makes a final decision — although it won’t include an assessment of how many people would be covered under the bill.

“Even over the weekend, I was receiving emails suggesting that the sponsors of the bill are still changing the formula,” Collins said. “So it may be difficult for the CBO to do the kind of in-depth analysis that it usually does, but that’s what I would like to see before making a formal decision.”

As for Paul, he showed no sign he’s ready to reverse his stance on Cassidy-Graham because, he believes, it leaves in place too much of the ACA’s spending (albeit turning it over to states). “I’m just not for this block-granting concept,” Paul said on NBC’s “Meet the Press.”

A video mashup of the Sunday shows:

PRICE CHECK

Health and Human Services Secretary Tom Price. (AP Photo/Jacqueline Larma, File)

–Hey, maybe you’ll spot Tom Price on your next airplane flight. The secretary of Health and Human Services will be flying commercially more often, saying yesterday that he’ll skip taxpayer-funded trips on private jets until his agency’s inspector general completes a review.

“I think that’s appropriate because of the concerns that we’ve heard,” Price said during an appearance Saturday on Fox News.

Reports about Price and his use of chartered jets at least two dozen times were damning enough to prompt an official investigation by the agency’s inspector general, The Post’s Aaron C. Davis reports. The IG’s spokeswoman told The Post on Friday that the agency will request records of Price’s travel and review the justification made by Price and his staff for the trips, which reportedly cost taxpayers a combined $300,000. House Democrats had requested the investigation, arguing the flights appeared to violate federal law designed to make sure executive branch officials use the most economical travel available.

“OIG is conducting a review of Secretary Price’s Federal travel using chartered aircraft. The review focuses on whether the travel complied with Federal Travel Regulations, but may encompass other issues related to the travel,” Tesia Williams, a spokeswoman for Levinson. “We take this matter very seriously, and when questions arose about potentially inappropriate travel, we immediately began assessing the issue. I can confirm that work is underway and will be completed as soon as possible.”

President Trump after getting off Air Force One on September 15. / AFP PHOTO / MANDEL NGANMANDEL NGAN/AFP/Getty Images

President Trump said yesterday that his administration is looking into the matter. “As far as Secretary Price is concerned, that’s different. We’re looking into it,” Trump told reporters in Washington, according to a pool report.

A few more good reads from The Post and beyond:

MEDICAL MISSIVES

STATE SCAN

REPRODUCTIVE WARS

DAYBOOK

Today

  • The National Press Club will hold an event on “Mental Health & The Opioid Crisis.”

  • Various groups, including the American Cancer Society Cancer Action Network (ACS CAN), American Diabetes Association, American Heart Association, American Lung Association, Consumers Union, and the National Multiple Sclerosis Society, hold a press event.

  • The Senate Finance Committee holds a hearing to consider the Graham-Cassidy plan.

Coming Up

  • The Brookings Institution will hold an event on “The Medicare Physician Fee Schedule and Alternative Payment Models” on Tuesday.

  • The House Financial Services Subcommittee on Housing and Insurance will hold a hearing on “examining insurance for nonprofit” on Thursday.

  • The American Enterprise Institute holds an event on “Innovative rethinking of health care delivery and competition” on Friday.

  • The National Press Club will have a headliners luncheon with FDA Commissioner Dr. Scott Gottlieb on Friday.

SUGAR RUSH

Sen. John McCain (R-Ariz.) speaks about his vote to kill Obamacare repeal:

Sens. Susan Collins (R-Maine) and Rand Paul (R-Ky.) list concerns about the Cassidy-Graham bill:

At a June town hall, Sen. Bill Cassidy (R-La.) touts coverage for preexisting conditions: 

Melania Trump hosts the first event in the White House garden:

From Late Night with Seth Meyers: Kim Jong Un calls Trump deranged and Sen. John McCain won’t vote for Obamacare repeal: 

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