By ROBERT PEAR
WASHINGTON – Just when the effort to repeal the Affordable Care Act appeared to be dead, a last-ditch push to obliterate the law could be nearing a showdown vote in the Senate, and a handful of Republicans insist they are closing in on the votes.
The leaders of the latest repeal effort, Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, say their drive is gaining momentum. But it is still a long shot. Under their bill, millions could lose coverage, Medicaid would see the same magnitude of cuts that earlier repeal bills extracted, and insurers in some states could charge higher premiums to people with pre-existing conditions.
Already, Sen. Rand Paul, R-Ky., has said he will not vote for the measure because it leaves too much of the Affordable Care Act in place.
And Sen. John McCain, R-Ariz., who cast the deciding vote that killed the repeal effort in July, expressed misgivings that the Senate would try again to pass a bill that had not been examined by committees with expertise – and with no Democratic support.
“Why did Obamacare fail? Obamacare was rammed through with Democrats’ votes only,” he said on CBS’ “Face the Nation” on Sunday. “That’s not the way to do it. We’ve got to go back. If I could just say again, the way to do this is have a bill, put it through committee.”
Sens. Susan Collins of Maine and Lisa Murkowski of Alaska, Republicans who opposed previous repeal efforts, have not said where they stand. But the new bill holds the same provisions that they opposed this summer: deep cuts to Medicaid and a temporary elimination of federal funding to Planned Parenthood.
Graham and Cassidy express a sense of urgency. If the Senate does not vote by the end of next week, it will become nearly impossible to repeal the law because the drive to kill the Affordable Care Act will lose the procedural protections that allow it to pass the Senate with a simple majority, rather than the 60 votes that would otherwise be needed.
The House passed a repeal bill in early May, by a vote of 217-213. But the seven-year Republican push to undo President Barack Obama’s signature health care law appeared to reach a dead end in July, when multiple versions of repeal legislation failed to gain even a simple majority in the Senate.
Refusing to accept defeat, Graham and Cassidy have come up with yet another bill. The Senate majority leader, Mitch McConnell, R-Ky., has told them he will find time for it on the Senate floor if they can muster 50 votes, which would ensure passage with Vice President Mike Pence on hand to break a tie.
McConnell is pressing the Congressional Budget Office for a quick analysis of the Graham-Cassidy bill.
The bill has two major elements, one that is new and one that was found in many other Republican repeal bills this year.
The new element is a block grant. Graham and Cassidy would give each state a fixed amount of federal money for health care and health insurance each year from 2020-2026. The allotments total $1.2 trillion over the seven years. That is slightly less than what the federal government is expected to spend under the Affordable Care Act on the expansion of Medicaid, on premium tax credits and on subsidies to reimburse insurers for reducing the out-of-pocket costs of low-income consumers.
States would have sweeping new discretion over how to use the money, and they could receive federal block grant funds without putting up state money.
In addition, the Graham-Cassidy bill would make deep cuts in Medicaid. It would end the expansion of eligibility under the Affordable Care Act, which has extended coverage to 13 million people.
And it would put the entire program, which serves more than 70 million people, on a budget, ending the open-ended entitlement that now exists. States would receive a per-beneficiary allotment of federal money.
The Congressional Budget Office has estimated that 15 million fewer people would have Medicaid as a result of similar proposals in other Republican bills. It is not clear when the budget office will issue a report on the Graham-Cassidy bill, showing its effects on federal spending and the number of people without insurance.
Graham and Cassidy would distribute federal block grant funds to the states using a complex formula that, like any such formula, creates winners and losers. It is difficult for any state to be sure how much it would receive. The authors of the bill say they intend to reduce expected federal payments to high-cost states like Massachusetts and increase federal payments to states that have not expanded Medicaid.
“Right now, 37 percent of the revenue from the Affordable Care Act goes to Americans in four states” – California, New York, Massachusetts and Maryland, Cassidy said. “That is frankly not fair.”
With the proposed block grant, Cassidy said, “we equalize how much each American receives toward her care, irrespective of where she lives.” By 2026, the per-beneficiary amount for each state would be within 10 percent of the national average.
Graham and Cassidy boast that their bill would also enhance the ability of states to waive “Obamacare regulations.” Insurers would still have to offer insurance to anyone who applied, but states could obtain federal waivers allowing insurers to charge higher premiums to sick people or to omit some of the benefits they are now required to provide, like maternity care, mental health care or treatment for drug addiction.
Coverage, while theoretically available, could become unaffordable for some people with costly conditions like cancer or AIDS, health policy experts say. “Less-healthy people would face extremely high premiums” in states that obtained waivers involving both benefits and premiums, the Congressional Budget Office said in analyzing a similar provision of the bill passed by the House.
Cassidy played down that concern. Under the Graham-Cassidy bill, he noted, a state seeking a waiver would have to describe how it intends to “maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions.”
The Cassidy-Graham bill would eliminate the requirement for most Americans to have health insurance and for larger employers to offer it to employees. Like prior Republicans bills, it would also cut off federal funds for Planned Parenthood for a year.
The House is unlikely to accept the bill in its current form. Some Republicans from states that lose money under the block grant could balk. But passage of the bill in the Senate could lead to negotiations with the House, reviving prospects for repeal of the Affordable Care Act.