The latest Republican healthcare plan to repeal Obamacare appears to be almost dead on arrival.
And there may be a good reason for that.
Nobody in the health industry likes it.
“This bill is as bad as or worse than the others,” Leni Preston, president of Consumer Health First, told Healthline.
The Cassidy-Graham bill, as it’s known, basically would give power to the states to form their own healthcare systems.
In addition, it would reduce Medicaid funding across the nation and provide the money as block grants to states to do with what they wish.
It would also redistribute some of the funds, mostly from states that expanded their Medicaid programs to those that didn’t.
The bill would take effect in 2020. The block grant funding for Medicaid would expire in 2027.
A vote on the legislation is expected this week in the Senate.
The Senate Finance Committee will hold a hearing today on the bill.
Tomorrow, the Senate Homeland Security and Government Affairs Committee is also scheduled to hold a hearing.
CNN is also hosting a town hall tonight featuring Sen. Lindsay Graham (R-South Carolina) and Sen. Bill Cassidy (R-Louisiana), the bill’s co-authors, as well as Sen. Bernie Sanders (I-Vermont) and Sen. Amy Klobuchar (D-Minnesota).
The bill must be approved before Saturday or Republicans lose the opportunity to approve the plan on a simple majority of 51 votes.
After that date, the bill can face a filibuster and could need 60 votes to pass.
Healthcare industry opposition
Although many Republican politicians still support the bill, it’s tough to find any group in the healthcare profession who will back it.
The past week, America’s Health Insurance Plans (AHIP) came out against it.
In a letter to the Senate, AHIP President Marilyn B. Tavenner listed six principles her organization feels a new healthcare bill should meet.
“The Graham-Cassidy-Heller-Johnson proposal fails to meet these guiding principles and would have real consequences on consumers and patients,” she wrote.
Officials at the Blue Cross Blue Shield Association were also critical.
In a statement, the association said:
“Although we support providing states with greater flexibility in shaping healthcare options for their residents, we share the significant concerns of many healthcare organizations about the proposed Graham-Cassidy bill.”
The American Hospital Association (AHA) also weighed in, listing several reasons why it opposes the bill.
“We believe that coverage could be at risk for tens of millions of Americans under the Graham-Cassidy proposal,” AHA President Rick Pollack said in a statement. “We continue to urge senators to work in a bipartisan manner to address the challenges facing our healthcare system.”
The American Medical Association (AMA) also joined in the chorus of criticism.
“Similar to proposals that were considered in the Senate in July, we believe the Graham-Cassidy Amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care,” said AMA Chief Executive Officer Dr. James L. Madara in a statement.
The American Academy of Pediatrics (AAP) had similar concerns.
“As a pediatrician, I am fearful for my patients and the uncertain future they would face under [the Cassidy-Graham] healthcare proposal,” said AAP President Dr. Fernando Stein in a statement. “I must speak out against this dangerous, ill-conceived policy on behalf of our 66,000 pediatrician, pediatric surgical specialist and pediatric medical subspecialist members, and stop it from advancing.”
These organizations are joined by dozens of consumer groups and other health-related organizations in opposition to the legislation.
In addition, the public doesn’t seem enamored by the latest Republican attempt to repeal the Affordable Care Act (ACA).
A survey released last week by Public Policy Polling stated that 50 percent of those questioned opposed the Cassidy-Graham bill while 24 percent supported it.
The poll also reported that 54 percent approve of the ACA while 38 percent disapprove.
A new Washington Post/ABC News poll showed that 56 percent of Americans prefer Obamacare to the latest GOP healthcare reform plan.
So, what specifically is so bad about the Cassidy-Graham bill?
Power to the states
The bill would eliminate the “individual mandate” requirement where people who don’t buy health insurance face a penalty on their income tax returns.
It also eliminates the “employer mandate” that requires larger companies to offer affordable insurance coverage to their employees.
The main provision, though, is giving states the power to craft their own healthcare systems.
Through a waiver process, states could keep or even add provisions to the ACA structure. States such as California could move toward a single-payer system.
States could also decide to drop certain ACA requirements.
That includes the provision that prevents insurance companies from denying coverage to people with preexisting conditions.
It also includes provisions that allow children to stay on their parents’ health insurance until age 26 as well as allowing insurance companies to create expensive high-risk pools or charge enrollees extra for a lapse in coverage.
In theory, a state could eliminate all of these ACA protections.
And that doesn’t sit well with a lot of healthcare professionals.
“The waivers are very broad,” Chris Sloan, a senior manager at Avalere health consulting firm, told Healthline. “You could have vast differences from state to state.”
In fact, Sloan notes, you could end up with 50 different plans in each of the 50 states.
Sloan said such a setup might discourage large, nationwide insurers from participating in regional or state marketplaces. They might just decide to provide only employer-backed health insurance.
California Congressman Eric Swalwell (D-Dublin), who has been one of the more vocal critics of Cassidy-Graham, said such a situation would be “chaotic.”
“You need national standards,” Swalwell told Healthline. “This would actually be worse than chaos. It would also be costly.”
Sloan said the legislation does give states some leeway in setting up plans, although he can’t find much else positive.
“States would enjoy the flexibility. I can see some states doing some innovative things,” he said.
The Citizens’ Council for Health Freedom (CCHF) is in firm opposition to Obamacare. They want the federal government out of the healthcare business.
One of their primary recommendations is to give states the authority over their health systems.
But even this group opposes the Cassidy-Graham bill.
Twila Brase, the CCHF’s president and co-founder, said the Cassidy-Graham is “on the right track,” but there are too many “strings attached” to its provisions and it still keeps the federal government in the healthcare system.
“It doesn’t do what Republicans promised they would do,” she told Healthline. “It’s just a Republican version of the ACA.”
The Cassidy-Graham bill would reduce federal health funds over the next decade from the current projected $489 billion to $215 billion, according to a report issued last week by Avalere.
In addition, the report says that 34 states and Washington, D.C., would experience funding cuts while 16 states would see funding increases.
Sloan said this would be accomplished by changing the formula for distributing these funds.
For starters, the Medicaid money would be part of the overall block grants given to states to spend on health programs.
In addition, he said, part of the money would be based on how many low-income residents a state has instead of how many low-income residents are being served in health programs.
This system, Sloan said, would provide additional money for states that didn’t expand their Medicaid programs under the ACA and less money for states that did.
Supporters of the bill say the funding reductions would force states to be more efficient with their healthcare dollars.
However, Preston of Consumer Health First isn’t buying it.
“It punishes states like Maryland that provided for its residents,” she said.
Swalwell sees the same problem.
“It rewards states for not taking care of the poorest of their citizens,” he said.
Sloan adds that the overall cut in Medicaid funding will create other problems.
“It will be challenging for states to cover as many people,” he said. “You can only stretch a dollar so far in healthcare.”
He said people who are just under the level to qualify for Medicaid might see that coverage go away.
“That person is going to be at risk of not having that money,” Sloan said.
These issues led all 50 Medicaid state directors to come out in opposition to Cassidy-Graham last week.
The votes don’t seem to be there
These and other problems are continuing to erode support for the Republican proposal.
Graham and Cassidy defended their plan on “ABC This Week” on Sunday.
They said they would “push ahead” with a vote this week.
Graham’s office didn’t respond to a Healthline request for an interview for this story.
The vast majority of Republicans in Congress still support the bill.
So does President Donald Trump.
This past week, the president said any GOP senator who votes against the Cassidy-Graham bill will be known as “the Republican who saved Obamacare.”
Nonetheless, Republicans need every vote they can get.
All 47 Democrats as well as the Independent Sanders are opposed to bill. That means if even three Republicans vote “no” the bill will lose.
On Sunday, Sen. Ted Cruz (R-Texas) said at the moment Republicans “don’t have my vote” for Cassidy-Graham.
On Monday afternoon, Sen. Susan Collins (R-Maine) announced she will vote "no" on the bill.
And Sen. Lisa Murkowski (R-Alaska) hasn’t said yet whether she will vote in favor of the legislation.
In an effort to woo Murkowski, Republican Senate leaders have added a provision to the Cassidy-Graham bill that would exempt Alaska as well as Montana from Medicaid spending caps that would be imposed on other states.
However, even if Murkowski supports the bill, the Republicans are going to have to convince at least two other senators to switch from “nay” to “aye.”