Daily on Healthcare: How the Graham-Cassidy bill lost the insurance industry

How Graham-Cassidy lost health insurers. The health insurance industry dealt a big blow Wednesday to Republicans by opposing an Obamacare overhaul bill considered their last shot at repealing the law. The powerful insurance trade group America’s Health Insurance Plans and the Blue Cross Blue Shield Association lashed into the bill on Tuesday. They join major healthcare groups such as the American Medical Association and American Hospital Association in opposing the bill. Insurers weighed in sparingly on previous Obamacare repeal debates, and never this forcefully. For instance, insurers were opposed to a “skinny” repeal bill that would have eliminated the law’s individual mandate and a measure from Sen. Ted Cruz, R-Texas, to let insurers sell plans that don’t comply with Obamacare’s regulations as long as they sold one that did. AHIP said in a letter to Senate leadership that the bill keeps a tax on health insurers and it erodes protections for people with pre-existing illnesses. AHIP was also concerned about whether the bill gives enough time for states to set up their own healthcare programs. The bill led by Republican Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana seeks to give Obamacare funding to states in the form of block grants. It would give states two years to set up their own Medicaid programs and individual marketplaces that would replace Obamacare’s exchanges. AHIP questioned if there was enough time for states to do that. “States need time to plan, analyze and make decisions that could have profound effects on their residents, local healthcare systems and on their state budgets,” the group wrote.

AHIP wasn’t just concerned about taxes and pre-existing illnesses. The insurance group was also worried about states adopting their own government-run, socialized healthcare programs, which they could do under the legislation. Sen. John Kennedy, R-La., has said he wants an amendment to Graham-Cassidy that prevents a state from using the block grant to set up a government-run healthcare system. But Graham shot down that amendment because it went against the premise of the bill: to give power back to states to create the healthcare programs that work for them. “You can’t have federalism on your terms,” he said earlier this week.

Another problem is lack of a coverage incentive, insurers said. Unlike previous repeal bills, Graham-Cassidy does not include an incentive for young, healthy people to sign up for insurance similar to Obamacare’s individual mandate. For instance, the House bill that passed in May added a 30 percent surcharge on premiums if someone lets their coverage lapse and tries to sign up again. Graham-Cassidy does not have any measure like that in the bill, presumably leaving it up to states to decide. The Blue Cross Blue Shield Association, which represents 36 Blue Cross Blue Shield insurers, was concerned that the lack of a mandate would create uncertainty in the individual market, which is used by people who don’t have insurance through a job. Cassidy’s office did not return a request for comment on whether the senator plans to add a coverage incentive to the legislation.

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Obamacare overhaul leaves pre-existing conditions up to states. Cassidy and Graham are fighting back against criticisms that their bill would erode protections for people with pre-existing conditions by saying that states can solve the problem. The bill lets states waive a protection called community rating that prevents insurers from charging sicker people more money than healthy ones. A state that wants a waiver from community rating has to prove that it will still provide adequate and affordable coverage for people with pre-existing conditions. However, adequate and affordable have not been defined, as that would be largely up to the secretary of Health and Human Services. Cassidy told the Washington Examiner that states have a slew of options to take care of people with pre-existing conditions. “They have a choice of things. Invisible high-risk pools is one example,” he said. A regular high-risk pool works by putting sick people into their own insurance pool, with the costs subsidized by the state. Other ideas include a regular high-risk pool or a reinsurance program in which a state helps cover the sickest claims. But other efforts to overhaul Obamacare have come back to the same problem with invisible high-risk pools: funding. The House’s Obamacare repeal bill included about $23 billion for high-risk pools and a state waiver for community rating. The nonpartisan Congressional Budget Office said the approach would lead to higher costs for sick people and the funding wasn’t enough.

New report finds Graham-Cassidy makes steep funding cuts. The nonpartisan Kaiser Family Foundation estimates that Graham-Cassidy would cut federal funding to states by $160 billion through 2026. This is the latest analysis to detail major funding cuts under the bill, but Kaiser’s estimates are below those of the left-leaning Center for Budget and Policy Priorities ($240 billion by 2026) and Avalere Health ($215 billion). Kaiser estimates the cuts would deepen to $240 billion in 2027 if the funding in the bill were not reauthorized. Even though funding overall would be cut, some states would see increases in funding due to redistribution. It aims to cut funds to states that expanded Medicaid and give more money to states that did not. Overall, a typical Medicaid expansion state would receive an 11 percent decline in federal funds from 2020-2026, while a state that did not expand Medicaid would get a 12 percent boost in funding. But the gains for some states could be wiped out due to per capita caps for all of Medicaid. Starting in 2020, the bill installs a per-capita cap funding system for all of Medicaid, not just the expansion population. A per-capita cap would limit federal funding based on the number of Medicaid beneficiaries. Kaiser estimated that under the plan, nearly all states would see a decrease in federal Medicaid funding by $53 billion nationwide from 2020 to 2026. “While some states would gain funding from the Graham-Cassidy (Affordable Care Act) block grant provisions compared with current law, the Medicaid per-enrollee cap proposal would offset some or all of those gains,” Kaiser said. “Ohio, Maine, and Louisiana are states where gains under the ACA block grant provisions are fully offset by the Medicaid changes, leading to a net loss in federal funds for those states.”

McConnell plans to hold a vote. Senate Majority Leader Mitch McConnell plans to bring the latest Obamacare overhaul bill to the floor next week, a McConnell spokesman confirmed. “It is the Leader’s intention to consider Graham/Cassidy on the floor next week,” said David Popp, a spokesman for McConnell. The Senate has until Sept. 30 to use the reconciliation tool that requires only 51 votes to repeal parts of Obamacare. Earlier Wednesday, Graham announced that the bill would reach the floor after meeting with Alaska Sens. Dan Sullivan and Lisa Murkowski. Murkowski is one of the key votes needed to pass the bill after she, Sen. Susan Collins of Maine and Sen. John McCain of Arizona voted against the “skinny repeal” bill in July. McConnell has told senators he would bring up the bill only if it has 50 votes. Vice President Mike Pence can cast the tie-breaking vote. But some Republicans such as Sen. Ron Johnson, R-Wis., another co-sponsor, have called for McConnell to bring it up even if they are short to put people on the record and pressure wary Republicans. McConnell could cancel a vote if he falls short. It has happened before. McConnell was dead set on holding a vote before the July 4 recess on the Better Care Reconciliation Act before nixing the idea because support collapsed.

Ryan promises action on Senate-passed healthcare bill. House Speaker Paul Ryan said the House would take up the Graham-Cassidy bill if the Senate can find the 50 votes needed to pass it next week. “If the Senate acts, we will act,” Ryan said during a Miami press conference during a tour of hurricane damage in Florida.

Pelosi: Graham-Cassidy bill a ‘stinkaroo.’ House Minority Leader Nancy Pelosi, D-Calif., dubbed the Graham-Cassidy healthcare bill a “stinkaroo” Wednesday as Senate Republicans look toward a possible vote on the legislation next week. “This is really a stinkaroo, this bill,” Pelosi told reporters during her weekly press conference, saying that the bill “with stiff competition” is their “latest and worst version.” “They had said to the American people it’s dead, it’s over, we’ve done it, but when … the parliamentarian of the Senate determined that their ability to do a bill with 51 votes would end on September 30th is when they knew they had to … try again and soon,” Pelosi said. “I think they like the fact that people are paying attention to hurricanes and earthquakes and DACA and this and that, and that they might be able to sneak this by. But it’s so terrible and people are understanding what it means in their lives,” she continued. “So I feel optimistic … But [I’m] never surprised around here.” The longtime California Democrat said there will be a “day of action” on Saturday and likely other rallies and protests in the coming week ahead of a potential vote and the deadline.

Trump touts ‘great’ Graham-Cassidy bill: President Trump said Wednesday that he has confidence that Senate Republicans can rally around a last-ditch proposal to repeal central parts of Obamacare, saying the current legislation is an improvement over the GOP healthcare bill that failed in the Senate earlier this summer. “I think there’s tremendous support for it,” Trump said of the bill. “I think it’s actually much better than the previous shot, which was sadly let down.” Speaking to reporters during a bilateral meeting with Egyptian President Abdel Fattah al-Sisi, Trump admitted that he thought healthcare reform would be far easier for his party to accomplish than it has been so far. “I thought that when I won, I would go to the Oval Office, sit down at my desk and there would be a healthcare bill on my desk,” he said, adding that “a lot of Republicans are embarrassed” that the party has struggled so significantly to repeal Obamacare. He also said he would not sign off on the bill if it did not include coverage of pre-existing conditions, which he asserted is included in the bill. “I would not sign Graham-Cassidy if it did not include coverage of pre-existing conditions,” Trump tweeted Wednesday. “It does! A great Bill. Repeal & Replace.” Later in the night he tweeted: “Senator (Doctor) Bill Cassidy is a class act who really cares about people and their Health(care), he doesn’t lie-just wants to help people!”

Jimmy Kimmel trolls Trump after he defends Cassidy. Late-night comedian Jimmy Kimmel responded to President Trump’s tweet saying that Cassidy was not a liar and wanted to help people after Kimmel called Cassidy was a liar on his show, “Jimmy Kimmel Live!” Tuesday night. “That’s great news Mr. President!” Kimmel tweeted in response to Trump. “Does that mean he’ll vote against the horrible bill he wrote?” Kimmel showed footage Tuesday of Cassidy from May when the senator said he would support a bill that would ensure no child could be denied healthcare, including emergency healthcare, if a family could not afford it.

Graham: Kimmel bought ‘liberal talking point’ ‘hook, line, and sinker.’ Graham defended his co-sponsor from Kimmel’s criticism. “I bet you he never called Sen. Cassidy and said would you please set this straight? I bet he looked at some liberal talking point, bought it hook, line, and sinker, and went after Bill Cassidy without talking to him, and I think that’s unfair,” Graham said on Fox News. Graham said his and Cassidy’s shared bill “requires pre-existing illnesses to be covered in the block grant,” the main point for Kimmel, who made a plea earlier this year to not deny anyone with a pre-existing condition health coverage after his newborn son was diagnosed with a heart condition.

‘Fox & Friends’ host responds to Kimmel calling him ‘a little creep.’ “Fox & Friends” co-host Brian Kilmeade on Thursday said late-night host Jimmy Kimmel should try interviewing lawmakers working on the Republican healthcare legislation instead of criticizing it from a distance. Kilmeade was responding to Kimmel’s opening monologue on ABC’s “Jimmy Kimmel Live” during which Kimmel played a clip of Kilmeade calling him one of the “Hollywood elites” who is “pushing their politics on the rest of the country.” Kimmel said he found the comment to be “particularly annoying” because Kilmeade is a “little creep” who “whenever I see him, kisses my ass like a little boy meeting Batman.” “This is what I would like to say on this,” Kilmeade said in return. “I hope your son gets better. I hope your son gets all the care he needs. I’m glad you’re interested, you’re doing a great job bringing the dialogue out. But you should do what we’re doing. Talk to the people that wrote it.” He went on to say he enjoyed Kimmel when he was a host on Fox Sports channel but that he thought the comedian would have a greater understanding of the new healthcare bill, dubbed the Graham-Cassidy bill, if he interviewed more lawmakers.

Obama: Republican efforts to overhaul Obamacare ‘aggravating.’ Former President Barack Obama said Wednesday it is “aggravating” to see the Republican-led Congress continue with its attempts to overhaul Obamacare, efforts he suggested would inflict “real human suffering” on people. “When I see people trying undo that hard-won progress, for the 50th or 60th time, with bills that would raise costs or reduce coverage or roll back protections for older Americans or people with pre-existing conditions — the cancer survivor, the expectant mom, or the child with autism, or asthma for whom coverage once again would be unattainable — it is aggravating,” Obama said during a keynote address at the Bill and Melinda Gates Foundation’s “Goalkeepers” event. “And all of this being done without any demonstrable economic or actuarial or plain common-sense rationale, it frustrates,” Obama continued. “And it’s certainly frustrating to have to mobilize every couple of months to keep our leaders from inflicting real human suffering on our constituencies.”

RUNDOWN

Wall Street Journal Health law repeal push could jeopardize children’s health insurance funding

The Hill Democrat on Trump pre-existing condition claims: “This is a lie.”

CNN The sleeping giant of pre-existing conditions awakens

Federalist How Graham-Cassidy’s funding formula gives Washington unprecedented power

Washington Post Behind the Senate GOP’s high-stakes healthcare gamble: unrelenting criticism back home

STAT news HHS hints at major changes to Medicare that could mean higher costs for patients

Politico The unlikely group who brought Obamacare repeal back to life

Associated Press Republicans see political necessity in healthcare effort

Des Moines Register Chuck Grassley: Fulfilling campaign promise just as important as “substance” of health bill

Roll Call Analysis: Why Paul Ryan has stepped into Senate healthcare debate

Calendar

SUNDAY | Sept. 24

Sept. 24-28. AHIP’s conference on Medicare, Medicaid and duals. Includes keynote by CMS Administrator Seema Verma. Details.

MONDAY | Sept. 25

10 a.m. 215 Dirksen. Senate Finance Committee to hold a hearing on the Graham-Cassidy-Heller-Johnson proposal. Details.

10 a.m. National Press Club. 529 14th St. NW. Discussion on “Mental Health and the Opioid Crisis” with healthcare workers and Rep. Tim Ryan, D-Ohio, co-chairman of the House’s Addiction Treatment and Recovery Caucus. Details.

WEDNESDAY | Sept. 27

3 p.m. Ronald Reagan Building and International Trade Center. 1300 Pennsylvania Ave.  Education Development Center  and the National Action Alliance for Suicide Prevention event on “From Pain to Promise – Addressing Opioids & Suicide in Communities Across America.” Details.