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McCain's 'No' Vote Threatens Graham-Cassidy Bill

Senator John McCain (R-AZ) may have torpedoed yet another Republican bill that overhauls the Affordable Care Act (ACA), a bill also opposed by the healthcare industry, or at least groups that purport to represent it.

McCain announced today that he could not support a bill sponsored by Sen. Bill Cassidy, MD (R-LA), Sen. Lindsey Graham (R-SC), and others without a full report by the Congressional Budget Office (CBO) on how the measure would affect healthcare coverage and insurance premiums. With one other Republican, Sen. Rand Paul (R-KY), a definite 'no,' Senate Republicans cannot afford any more defections in their quest for the 50 votes needed for passage (Vice President Mike Pence is counted on to cast the tie-breaker). The party enjoys a 52-seat majority. Yet several other Republican senators who joined McCain in quashing the last GOP repeal-and-replace bill may line up with him against the Graham-Cassidy bill.

The CBO says it won't have an estimate of the bill's impact on coverage or insurance premiums until several weeks from now. However, the agency plans to issue an analysis early next week of how it impacts the federal budget, presumably before the Senate votes. Supporters have pushed for a vote next week, before the September 30 expiration of a parliamentary maneuver that makes the bill filibuster-proof — and lowers the threshold for victory to 50 ayes.

Major healthcare groups like the American Medical Association (AMA), the American Hospital Association, America's Health Insurance Plans (AHIP), and the American Nurses Association have warned that the Graham-Cassidy bill would roll back coverage gains and consumer protections achieved under the ACA. They also fault Senate Republicans for not wanting to wait for a full CBO report on the measure's ramifications.

In a nutshell, the legislation would take money earmarked for ACA provisions such as premium subsidies and Medicaid expansion, give it to states in the form of block grants through 2026, and let them spend it on their own reforms. The bill also would limit once open-ended federal contributions to state Medicaid programs by converting them to block grants or capping them on a per-capita basis — states can take their pick. The individual mandate to purchase coverage as well as Medicaid expansion would go by the wayside.

The bill, as Lindsey put it recently, "breaks [the] Obamacare mold by sending money and power back to the states, and closer to patients, to deliver quality healthcare."  

Some policy analysts have crunched the numbers to come up with projections that resemble those for previous Senate Republican measures to repeal and replace the ACA. The consulting firm Avalere Health estimates that, under the Graham-Cassidy bill, states would receive $215 billion less in federal funds through 2026, with states that had expanded Medicaid taking the biggest hits.  And up to 18 million people could lose coverage in 2019, and more than 32 million after 2026, when the temporary ACA-financed block grants expire, according to the Commonwealth Fund.

Commentators all around also point to the ability of states to let insurers drop once essential benefits like maternity care, and base premiums on health status — meaning pre-existing conditions. That isn't possible now under the ACA.

"Do No Harm" Principle Would Be Violated, AMA Says

Major medical societies have reacted to the Graham-Cassidy bill with alarm.

  • The measure "violates the precept of 'first, do no harm,' " said James Madara, MD, the AMA's executive vice president and CEO, in a letter to Senate leaders. It would "allow insurers to charge unaffordable premiums based on…pre-existing conditions."

  • A letter signed by another six medical societies struck a similar note about threats to consumer protections. In addition, there was the danger of a "healthcare system built on state-by-state variability" that would jeopardize the coverage of millions, said the American College of Physicians, the American Academy of Family Physicians, the American Osteopathic Association, the American Academy of Pediatrics, the American Psychiatric Association, and the American Congress of Obstetricians and Gynecologists.

  • In a joint statement, the Infectious Diseases Society of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society criticized the bill for eliminating the ACA's Prevention and Public Health Fund, which accounts for more than 12% of the budget for the Centers for Disease Control and Prevention.

Dental Images of Cavities, Dry Sockets, Gingivitis

The American College of Cardiology and the American Gastroenterological Association also have expressed serious misgivings about the bill.

Elsewhere in the healthcare industry, American Hospital Association President and CEO Rick Pollack said that the Graham-Cassidy bill does nothing to stabilize the insurance market "now or in the long term."  AHIP, not always an ally of physicians and hospitals, called the legislation destabilizing, as well.

AHIP President and CEO Marilyn Tavenner said that Congress could steady the individual insurance market by continuing to reimburse insurers for reducing out-of-pocket expenses for low-income individuals covered by ACA exchange plans. The bill eliminates these "cost-sharing reduction" payments to insurers, which are authorized by the 2010 law.

Other healthcare groups urging the Senate to defeat the Graham-Cassidy bill are the Association of American Medical Colleges ("dramatic increases in the number of uninsured") and the American Nurses Association ("drastic and dangerous cuts").

Opponents of the bill inside and outside of healthcare have complained that Senate Republicans have abandoned "regular order" to win passage before the end of September. One aspect of regular order is reliance on CBO findings. Another aspect is assessing and improving a bill on a bipartisan basis through committee hearings. Yet only one committee hearing for the Graham-Cassidy bill has been scheduled so far — by the Senate Finance Committee, for September 25.

Reviewed on 9/25/2017

McCain's 'No' Vote Threatens Graham-Cassidy Bill - Medscape - Sep 22, 2017.

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