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« You stopped Trumpcare! Again! | Main | This week’s view from Washington, D.C »

Radical Trumpcare bill is gaining speed!

We’re back on high alert for the most radical Trumpcare bill yet!
Last week, we warned that Senate Republicans might make one last push to repeal the Affordable Care Act (ACA) and gut Medicaid before they run out of time. This week, we’re moving to red alert in response to reports that Republican leadership is gearing up for a vote the week of September 25, and a possible sham hearing before then.
Now is the time to call, write and rally to urge senators to reject this new threat! Tell them to instead support a bipartisan package to stabilize the insurance markets and fund the cost-sharing reductions that make coverage more affordable for many of us. You can call Congress toll-free at 844-898-1199.

The bill is known as Graham-Cassidy-Heller-Johnson for its sponsors—Senators Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI). This legislation is being sold as a “compromise” and “non-partisan” solution, even though no Democrats support it. Not only is Graham-Cassidy not a compromise, it is the most radical proposal yet.  The bill goes far beyond Republicans’ campaign pledge to repeal the ACA, including Medicaid expansion. This measure also attacks long-standing traditional Medicaid.  
Republicans have only two weeks to ram through repeal with just 50 senators, plus the tie-breaker vote from Vice President Mike Pence. That’s because on September 30, when the current fiscal year ends, the special process known as “reconciliation” will turn back into a pumpkin and Republicans will once again need 60 votes to overcome a filibuster on any health care package.
Medicaid and the ACA
What’s at stake for women and families in the Medicaid portion of this latest Trumpcare bill? Traditional Medicaid, enacted in 1965, is sometimes described as “low-income and...” because to qualify, an individual must fit into a second category—such as low-income and pregnant, low-income and disabled, low-income andelderly.  Prior to the ACA, simply living below the poverty line wasn’t enough to qualify for coverage in most states, so millions of low- and middle-income adults had no access to health insurance.
The ACA, enacted in 2010, increased coverage in two ways. First, for those living below 138 percent of the federal poverty level, the ACA expanded Medicaid, giving low-income adults who didn’t otherwise qualify for Medicaid the same guarantee of high quality coverage. The ACA as written made the Medicaid expansion mandatory for all states, but in 2012 the Supreme Court made it optional. Nineteen states have refused to expand, leaving millions of their residents in a coverage gap. The intra-party battle in Congress this year has been heavily influenced by the dispute between the Republican governors who responsibly covered their constituents by expanding Medicaid and those who didn’t and now want to be rewarded by the party for fighting “Obamacare” at the expense of their constituents and state budgets.
The second way the ACA expanded coverage was by helping low- and moderate-income households living over the federal poverty line buy private health insurance in the individual market. The ACA subsidizes both premium expenses and out-of-pocket costs like co-pays and deductibles.
Under current law, everyone who is eligible for Medicaid or for financial help purchasing private coverage is entitled to it. That coverage guarantee means that the programs are flexible enough to respond to economic downturns, natural disasters, rising medical costs, and an aging population. By contrast, Graham-Cassidy would end these guarantees for both Medicaid and the ACA.

Graham-Cassidy Guts Traditional Medicaid
Graham-Cassidy would replace traditional Medicaid’s 50-year federal-state partnership with a cap-and-slash system designed to cover less and less each year. Under current law, Medicaid automatically adjusts when public health crises like those resulting from Hurricanes Harvey and Irma suddenly drive up per-person costs. But under Graham-Cassidy, once the federal per-person spending cap has been reached, federal funding cuts off. And natural disasters aren’t the only variables sure to raise costs.
The Center on Budget and Policy Priorities (CBPP)  warns that under a per capita cap, “federal funding [in traditional Medicaid] for seniors, people with disabilities and families with children would no longer automatically increase to account for higher costs such as prescription drug price spikes or rising costs resulting from an aging population. States would be responsible for 100 percent of all costs above the cap.”
So how does Graham-Cassidy expect states to cope with these huge cuts? By dropping coverage (like prescription drugs) and dropping people (like pregnant women) that they are currently required to cover.
Graham-Cassidy Repeals the ACA and Replaces It with … Nothing
Starting in 2020, Graham-Cassidy completely eliminates the ACA’s Medicaid expansion and subsidies for purchasing private insurance. As Cassidy himself tweeted, Graham-Cassidy “repeals entire architecture of Obamacare.”
In its place, the bill calculates how much money the federal government would have spent on ACA programs, cuts that by over one-third, and then redistributes the much smaller pot as block grants to the states with few strings attached. While the ACA includes consumer protections that prevent insurance companies from selling worthless “junk” insurance, rescinding coverage the moment someone gets sick, or discriminating against people with pre-existing conditions,Graham-Cassidy gives states free rein to reinstate all of the worst insurance practices of the bad old daysThat means insurance companies could once again charge non-smoking women more than smoking men, treat rape and domestic violence as pre-existing conditions, and reinstate annual and lifetime caps on coverage.
Even worse, there’s no requirement that states actually spend the money on providing coverage to low- and middle-income families. States would be free to spend the money on any purpose tangentially related to health care, and could design programs that discriminate against women, people of color, immigrants, LGBTQ people and other marginalized communities.
Initially, the 19 states that have thus far refused to expand Medicaid—leaving millions of their residents without care—will get an increase in ACA dollars by taking money away from the states that covered their residents. While the bill’s formula for distributing funds is complicated, it can be summed up in under 140 characters, as tweeted by conservative Senator Rand Paul (R-KY): “#GrahamCassidy … redistributes money from dem states to republican states.”
But even many of those Republican states will actually still face deep cuts once the per capita cap on traditional Medicaid is factored in. Analysis by CBPP finds that all but eight states will lose millions to billions of dollars under Graham-Cassidy in the years between 2020 and 2026.
But, no state will benefit for long. That’s because after 2026 under Graham-Cassidy, traditional Medicaid will be reduced by over one-third, while the ACA-turned-block grant funding will disappear altogether to be replaced with… nothing. That’s right, starting in 2027, the bill eliminates every last dollar spent on the ACA.
Finally, the bill once again attacks the ability of women and men to use Medicaid or other forms of government health insurance at Planned Parenthood for services like cancer screenings, STD treatments, family planning services like birth control, and more.

What’s Happens Next?

Senator John McCain (R-AZ), who dramatically voted against an ACA repeal in July out of concern that the bills hadn’t gone through “regular order”—including a bipartisan process of committee consideration—has said that he supports the bill (bill sponsor Graham is his best friend).  But he has hedged about whether he could support it in absence of a committee process. In response, bill co-sponsor Johnson told the press, “I’m chairman of Homeland Security. If either the Finance Committee or HELP committees [with jurisdiction] won’t hold a hearing, I’ll [set up] one this afternoon,” simply to check that box.

Under Senate rules, Graham-Cassidy will need a budget “score” from the Congressional Budget Office (CBO) and a “Byrd bath” from the Senate parliamentarian—the process of determining whether individual provisions qualify under the “Byrd rule,” which limits what can be included in a reconciliation package. Republican leaders are pushing for a partial CBO score by next week, one that shows the fiscal impact but not the number of people harmed by cuts to their care.
Should Republicans secure 50 votes on Graham-Cassidy or any other Trumpcare proposal, they will be able to pick up from where they left off in July, with all debate time expired and only the rapid-fire amendment process known as vote-a-rama left. In other words, some of the most consequential legislation in our nation’s history, affecting one-fifth of our economy, could get a vote after only 5 minutes of debate on the Senate floor.
If we can prevent the Senate from passing repeal legislation before September 30, we will have blocked their ability to pass Republican-only health care legislation for the foreseeable future. But if the Senate passes Graham-Cassidy, the House faces no similar time limit on their ability to pass the bill. They could—and likely would—move to immediately take up the Senate bill and pass it without changes, sending it to Donald Trump for signature. But they could also use the remaining 15 months of this Congress to pressure blue state Republicans to vote for the bill and stymying hope for a bipartisan package.
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