The Senate is expected to vote on the Graham-Cassidy-Johnson-Heller Medicaid block grant/per capita cap this week, with shifting odds of passage. Over the weekend, more questions than answers were being raised about its prospects, especially after Senator John McCain (R-AZ) said on Friday that he could not vote for the bill yet due to the procedure the Senate was using to pass the bill. The bill must pass before the September 30 deadline for reconciliation expires.

CWLA has already filed a statement in opposition to the Senate Finance committee. The Legislation will create a block grant of Medicaid expansion funds and ACA subsidies and re-distribute funds, in-part, from states that expanded Medicaid to states that did not expand care. In addition it will convert the Medicaid program into a per capita cap that will result in ending the entitlement to health care coverage through Medicaid.

If the Senate were to pass the bill this week, there is a very good chance that the House of Representatives will adopt the same legislation.

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Families USA has an analysis of the Graham-Cassidy. The Senate Finance Committee has scheduled a hearing for today. The hearing was scheduled to address criticism that the Graham bill has not gone through Committee. This was all part of a rapid-fire set of developments that took place last week.

In short order last week, Senator Lindsey Graham (R-SC), who does not sit on either Senate committee of jurisdiction (HELP, Finance), announced with Senator Bill Cassidy (R-LA) that the bill was gaining traction in finding support. Senator McConnell (R-KY) announced there would be a Senate vote, Senator Lamar Alexander (R-TN) announced the end of his HELP Committee negotiations on a bipartisan fix (that was gaining traction), and the President started to tweet his support—all of this happening over a 48-hour period.

The last attempt at repeal failed last month when only 49 Republicans supported the bill. That final vote, however, was for a “skinny” repeal bill that was limited and designed to go to a Senate-House negotiation that could have been considered over the summer break. This time, this bill will go to the House, where they will have to approve it or reject it with no negotiation and a September 30 deadline. As the last chance to repeal, it is anticipated by many that Speaker Paul Ryan (R-WS) will get the 218 House Republicans he needs to support it.

Senator Susan Collins (R-ME), Senator Lisa Murkowski (R-AS), and Senator John McCain (R-AZ) were the “no” votes last month, but with this bill, the fate is less clear. Along with Senator McCain’s Friday announcement against the bill, it is believed that Senator Collins will oppose the measure. Senator Murkowski’s current position is still open, but Senator Rand Paul (R-KY) has said he is a definite “no” because the bill does not go far enough to repeal the ACA. As a result, the President has taken to criticizing him through various tweets.

At this point, opposition is not certain and provisions in the bill are changing.  The final vote count and the bill could all still change between now and September 30.

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Impact on the HELP Committee and Other Priorities

When Majority Leader McConnell announced his intention to vote on the bill, the renewed debate had the proverbial effect of sucking the oxygen out of the political room.

The HELP Committee efforts were abruptly ended when Senator Lamar Alexander (R-TN) started getting pressure from other Republicans including Finance Committee chair Senator Orrin Hatch (R-UT). Chairman Alexander had hoped to reach a deal early last week but stopped those efforts. He is listed as a supporter of the Graham-Cassidy bill.

In addition to that action, earlier progress around the reauthorization of the CHIP insurance program and the home visiting programs were pushed off to the sides as the tension in the Senate rose.

What It Does

The bill enacts two major changes.  It creates a new block grant while also converting Medicaid into a capped program.  The block grant takes all the Medicaid funding that comes from the 31 states that took the option to expand Medicaid coverage, combines those funds with other ACA credits and subsidies, and distributes these funds through the new block grant. It has the effect of taking money from a majority of states and shifting it to others. By various estimates, including one by the Administration that was leaked to the Washington Post, more than 30 states would lose funds. States like California, New York, and Maryland are clear losers, while states like Mississippi and Senator Graham’s state of South Carolina make out with increased funding.

The bill also converts the traditional Medicaid program into a per capita cap; a complex block grant would cap funding to all states and eventually shift more health care costs away from the federal government to the states.

Opposition Grows

By Sunday, the organizations expressing opposition was exploding. Among the groups opposing the legislation where medical associations, business groups, advocate organizations like CWLA and state groups.  A few include: the American Medical Association, the Alzheimer’s Association, the American Academy of Pediatrics, American Diabetes Association, the American Hospital Association, AARP, the ARC, Autism Society, Families USA, the American Lung Association, the American Cancer Society, Cancer Action Network, the American Heart Association, the Association of American Medical Colleges, the Children’s Hospital Association, the Catholic Health Association, American Health Insurance Plans, the March of Dimes, Coalition to Stop Opioid Overdose, Lutheran Services in America, Kaiser Permanente, Planned Parenthood, Robert Wood Johnson Foundation, the Blue Cross Blue Shield Association, and the National Association of Medicaid Directors.

The Graham-Cassidy bill is operating on a limited timeframe itself. On September 30, the reconciliation instruction that allows the Senate to approve a repeal bill will run out. Congress could write a new reconciliation for 2018, but they want to save that for a tax cut package.

Normally the Congressional Budget Office (CBO) must score the bill to determine cost, savings, and impact on health insurance coverage, but they have been directed to speed up that process by focusing solely on cost savings. They are unlikely to produce an analysis that will examine the impact on insurance coverage. That study is expected to come out today.