ACA Repeal and Replace Legislation

The latest iteration of legislation to repeal and replace the Affordable Care Act (ACA) is the Graham-Cassidy bill which would create a block-grant program that would affect states very differently depending on whether they expanded Medicaid under the ACA.  Expansion states are likely to see their funding reduced and redistributed to non-expansion states through the block-grant formula. It would repeal the Prevention and Public Health Fund beginning in fiscal year 2019, restructure and cut Medicaid, repeal the ACA’s premium tax credit, cost sharing reduction payments, and individual and employer mandates, and weaken or eliminate protections for people with pre-existing conditions.

As a reminder, the Senate is attempting to take up this latest repeal and replace proposal under special rules—called reconciliation—which allows the package to pass with 50 votes (with Vice President Pence casting a tie-breaking vote) instead of the Senate’s usual 60 vote requirement.  The Senate can only use these special rules for health care legislation through the end of the fiscal year, September 30.

Senate Majority Leader Mitch McConnell plans to have the Senate consider the Graham-Cassidy proposal on the floor on Wednesday, September 27, and Senate Finance Chair Orrin Hatch has scheduled a committee hearing on the bill for Monday, September 25.  According to two analyses of the bill, from the Center for Budget and Policy Priorities and Avalere Health, the Graham-Cassidy plan  lowers federal funding significantly with less money being put toward health care programs.  One analysis showed a reduction in federal funding to states by $215 billion through 2026 and more than $4 trillion over a 20-year period. Thirty-four states and the District of Columbia would face cuts. Avalere also gives information on how the cuts would vary by state, especially for those that expanded Medicaid.

The Congressional Budget Office (CBO) plans produce a preliminary analysis of proposal by early next week but this preliminary assessment will only outline if the Graham-Cassidy proposal reduces the deficit enough to be considered under the Senate’s reconciliation procedure.  Per Senate rules, before the Senate votes, rulings on if proposal meets the deficit reduction requirements and if it meets the reconciliation requirements must be made.  These will all likely occur early next week.   Should the Senate vote occur on Wednesday as currently rumored, that vote will occur without additional information from the CBO on the full impact of the proposal on health insurance coverage, access, and costs.

If the Senate can get to the 50 required votes is still unclear—Senators Murkowski and McCain are the votes everyone is watching.  It is likely that this proposal will still come up for a vote even if the 50 votes are not secure so that Congress can show again that it is attempting to fulfill their campaign promises. If the bill proceeds out of the Senate, House members would then vote on it with no opportunity for changes—all by September 30.  Stay tuned—it’s likely going to another roller coaster week next week!

Bipartisan committee efforts to stabilize the insurance market appear to be in peril while the Graham-Cassidy bill is on the table. NCSD joined with national partners to urge Senate Republicans to protect the health care needs of vulnerable individuals living and at risk for HIV and other STDs by opposing the bill.  NCSD has also joined a letter from the Health Care Access Work Group of the Federal AIDS Policy Partnership to Senate offices outlining concerns and opposition to the bill.

Budget

There are reports that an agreement has been reached among Senate Republicans to move a budget resolution through the Senate Budget Committee and to the floor.  While many details are not yet known, it would be expected to include reconciliation instructions that would allow a $1.5 trillion tax cut package to pass in the Senate with 50 votes (plus Vice President Pence to break a tie), rather than a 60 vote supermajority.  The tax cut would increase the deficit—there would be no requirement that other revenues be raised to offset the cost of the tax reductions.  Timing of the release is subject to change depending on what is happening with votes on the Graham-Cassidy health care bill but it is possible that the Senate Budget Committee could release the draft resolution as soon as Friday, September 22.  If they are able to approve a budget in committee, it would be expected to go to the floor the first week in October, with the aim of passing it before they leave on Friday, October 6 for the Columbus Day recess (the Senate will be out October 8-13).