The US Senate is taking another stab at repealing and replacing the Affordable Care Act (ACA), this time with a plan that could disproportionately hurt the Medicaid programs in Oregon and Washington. Oregon could be one of the hardest hit states, with more than a $3 billion loss over the next decade.
Along with 18 other states ranging from New York to North Dakota, Oregon and Washington expanded Medicaid eligibility under provisions of the ACA. The latest version of the Cassidy-Graham bill in the Senate would effectively scrap discrete federal funding for the expansion as part of a plan to give states Medicaid block grants.
“The revised version of the Cassidy-Graham plan would disproportionately harm certain states,” according to the Center of Budget and Policy Priorities, a nonpartisan research and policy institute that analyzes how federal budget priorities impact low-income Americans. “The block grant would not only cut overall funding for the Medicaid expansion and marketplace subsidies, but also starting in 2021 redistribute the reduced federal funding across states based on their share of low-income residents rather than their actual spending needs.”
The Center says states that expanded Medicaid eligibility, including Oregon and Washington, could end up receiving 35 to 60 percent below what they get now from the federal government under current law. That would exacerbate Oregon’s budgetary challenge if the Medicaid funding package approved in the 2017 legislative session is referred to and rejected by voters in a special election next January.
After a dramatic Senate floor showdown in August that failed to approve a previous GOP proposal to repeal and replace the ACA, it seemed as if congressional Republicans had decided to move on to other issues, including tax reform. The proposal by GOP Senators Bill Cassidy and Lindsey Graham seemed to come out of nowhere and has sparked speculation it could get enough votes to pass.
Senate Republicans only have until September 30 to approve an ACA repeal and replacement measure with 50 votes under complicated budget reconciliation procedures. That means Senate Republicans, who hold a slim 52-member majority, can only afford to lose two of their members on the repeal vote. A 50-50 tie vote would be broken under Senate rules when Vice President Mike Pence cast a vote. The Trump White House has signaled it would support the Cassidy-Graham bill. GOP Speaker Paul Ryan has indicated he would push for House passage.
Opponents say the Cassidy-Graham measure also would destabilize the individual health insurance market by eliminating ACA subsidies and allowing states the flexibility waive essential benefits and weaken the pre-existing condition provisions in the ACA.
“While insurers would still be required to offer coverage to people with pre-existing conditions,” the Center says, “insurers could charge unaffordable premiums of thousands or tens of thousands of dollars per month, effectively resulting in a coverage denial.”
Insurers also could offer plans with large benefit gaps such as maternity care, substance abuse treatment and mental health services, which a Kaiser Family Foundation analysis was a common pattern in health insurance before passage of the ACA.
The impact could be even greater as the Cassidy-Graham bill reduces the per capita allocations in block grants for all states starting after 2026. “Many states would likely cut home and community-based services, which allow people needing long-term services to remain in their homes rather than moving to a nursing home,” according to the Center.
If Senate Republicans are unable to muster the necessary 50 votes for Cassidy-Graham in the next 10 days, then all the dire predictions will be put aside.
Another casualty of Cassidy-Graham has been the bipartisan effort in the Senate Health Committee to find politically acceptable ways to stabilize the individual health insurance marketplace and reduce pressure on higher premiums. Senator Lamar Alexander, the GOP chairman of the committee who was working with Washington Senator Patty Murray, said no consensus was reached. The effort was undercut when Ryan said the House wouldn’t consider a bipartisan stabilization bill.
A group of 10 governors representing Medicaid expansion states sent a letter to Senate leaders urging a continuation of bipartisan efforts on the ACA, saying that the way to “achieve true, last reforms.” One of the governors is John Bel Edwards of Louisiana, which is the home state of Senator Cassidy.
Louisiana Secretary of Health Dr. Rebekah Gee sent a letter directly to Cassidy that said, “In its current form, the harm to Louisiana from this legislation far outweighs any benefits. Therefore, I must register our deep concerns and hope we can find a better path forward toward fixing the broken parts of our healthcare system.