Here they go again!
Sens. Lindsey Graham (R-SC) and William Cassidy (R-LA), together with Sens. Ron Johnson (R-WI) and Dean Heller (R- NV), have just proposed the Senate GOP's latest effort to repeal the Affordable Care Act (ACA). Republicans are trying to force a vote before the clock runs out on the reconciliation process at the end of September, so that only a 51-vote majority is required for repeal. Like its shipwrecked predecessors—the American Health Care Act, the Better Care Reconciliation Act, and the aptly named “Skinny” Act—the effects of this new proposal would be devastating.
Beginning in 2020, the Cassidy-Graham bill would cut federal insurance and cost-sharing subsidies for the ACA state health insurance marketplaces, as well as for enhanced federal financial support to the 31 states and Washington, D.C. that are participating in the Medicaid expansion. Instead these funds would be block granted to states. The net result would not be the status quo, however. States that participated more in the ACA—such as New York and California—would be penalized financially, and those that did not would be rewarded financially. These cuts would reach 40% by 2026 and grow ultimately to 100% when the block grants end in 2027, with no forward plan beyond that year.
Federal participation in the overall Medicaid program itself also would be block granted beginning in 2020, using a per-person formula. Over time, the per-person amount would fall farther and farther behind the actual cost of care and result in progressive limitations on needed care for each person covered.
Together, these actions would virtually reverse and then eliminate the major gains in health insurance coverage that have been achieved through the ACA. As a result, they would have dire consequences for Americans who are poor or near-poor, those who have disabilities, and those who are older. We estimate that:
- 15 million people would lose health insurance coverage in the short run
- 32 million people would be uninsured by 2027
- About $500 billion would be stripped from the ACA and the Medicaid program.
Further, the individual and employer insurance mandate would be eliminated, with potentially catastrophic consequences on the individual and group health insurance markets. States would have flexibility to determine whether to cover costs associated with some conditions, and older persons could end up paying up to five times as much as at present for health insurance. Thus, key health insurance protections instituted by the ACA would be swept away.
For those who need behavioral healthcare, the effects could even be much worse. States would be given flexibility on essential health benefit coverage. This would mitigate or eliminate parity protections for mental health and substance use benefits. Essential types of care could be out of reach entirely for many.
All of these changes would put us on a slippery slope leading to the elimination of guaranteed insurance issue, elimination of premiums that are community rated, and elimination of guaranteed benefits for mental health and substance use care. Although done under the guise of state flexibility, the real goal of these changes would be to reduce dramatically the financial role of the federal government in healthcare.
So, what is the bottom line? The Graham-Cassidy bill is just as bad as or even worse than the earlier bills proposed by Senate and House Republicans.