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How Graham-Cassidy measures up to Lisa Murkowski's standards for health care reform

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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The Alaska Auction is on.

Sen. Lisa Murkowski (R-AK) is maybe the decisive swing vote on Graham-Cassidy, the GOP's last hope to pass an Obamacare repeal bill. With Sens. Susan Collins (R-ME) and Rand Paul (R-KY) penciled in as "no" votes, Murkowski would be enough to sink the bill if she came out against it.

Over the past two days, it's become clear that Senate Republicans are doing everything they can to funnel more money to Alaska and persuade Murkowski that this is the Obamacare repeal bill she should back. Take a look:

  • Business Insider eyed an oddity in Sen. Bill Cassidy's spreadsheets that suggests Alaska could end up receiving an additional bump to its block grants under the bill.
  • Politico noticed that Alaska could also end up being exempted from the bill's Medicaid spending caps.
  • Now IJR is reporting that the plan might be revised to allow Alaska (along with Hawaii) to keep the Obamacare tax subsidies, while also still receiving block grant money.

Nothing is baked in until we see a final bill — the rumor mill in Washington is working overtime right now, based on my own discussions.

But remember: Every outside analysis we've seen estimates that Alaska would lose funding under Graham-Cassidy.

Avalere Health projected a $1 billion (or 10 percent) cut by 2026. The left-leaning Center on Budget and Policy Priorities, under a slightly different rubric, found the state's funding would be $255 million lower in 2026. The Kaiser Family Foundation has pegged Alaska's losses at $275 million over 10 years.

Nevertheless, Murkowski is undecided on the bill. She's said she's still looking at the funding numbers and how her state would be affected by Graham-Cassidy.

This got me thinking about an afternoon in mid-June, when I took a walk with Murkowski through the basement of the Senate office buildings (we got lost more than once) and talked about her party's plans for Obamacare repeal.

She set some pretty clear standards, I think, for what she wants out of health care reform. Let's see how Graham-Cassidy measures up.

"[Alaskans] know what they do like. They do like the fact that they have gotten coverage for preexisting conditions."

This issue has been well litigated, as Cassidy spars with late-night host Jimmy Kimmel. Under Graham-Cassidy, if states choose to permit it, insurers could once again charge people higher premiums based on their medical history

Cassidy has sought to dispute that, pointing to a provision that requires states to describe how they would provide adequate and affordable coverage to people with preexisting conditions if the state seeks such a waiver.

But as Sarah has already explained after talking to policy experts, that is hardly the rock-solid guarantee that Obamacare currently provides, which prevents discrimination based on medical need.

"I want greater access and lower costs. ... If you are going to eliminate Medicaid expansion or even if you're going to wind down Medicaid expansion, that's not increasing access."

Alaska expanded Medicaid under Obamacare, and, along with the law's private insurance expansion, that helped lower the state's uninsured rate from 18.9 percent to 11.7 percent over the past few years.

Graham-Cassidy ends the Medicaid expansion. It's not at all clear that Alaska could reconstruct it on its own, considering the block grants would be a funding cut compared to Obamacare, though the funding picture could change if Alaska gets to keep the Obamacare tax credits.

Maybe the simplest way to think about it is: Alaska Gov. Bill Walker pushed Medicaid expansion through in Alaska, and he opposes Graham-Cassidy.

"We're setting ourselves up for the same criticism we waged against our colleagues on the other side."

This is what Murkowski said when I asked her about the secretive process that produced the original repeal bill. That plan was produced without any public hearings, expert testimony, or markups.

The same is true of Graham-Cassidy. The Senate Finance Committee is convening a hearing next week, but it is quite clearly for show, an attempt to assuage the concerns of Sen. John McCain (R-AZ), who is also holding out support because he opposes the process that produced these bills.

The Congressional Budget Office has said it won't be able to provide analysis on how many people would be covered under Graham-Cassidy or what would happen to premiums, prior to the vote. This is a long way from regular order.

All in all, it's hard to see how Graham-Cassidy has addressed the conditions that Murkowski laid out in June. Preexisting conditions are back. Medicaid expansion is ended. The process has been as abnormal as before.

But the bill's proponents seem to think her vote is still in play, and they're willing to spend a lot of money to win her over. That brings us back to one other old quote from Murkowski, via Bloomberg:

“Let’s just say that they do something that’s so Alaska-specific just to, quote, ‘get me.' Then you have a nationwide system that doesn’t work. That then comes crashing down and Alaska’s not able to kind of keep it together on its own.”

GIF of the Day

Javier Zarracina / Vox

Graham-Cassidy's funding cuts by state. Murkowski's situation makes clear how important the different state effects of this bill are to its chances of passage. This GIF, based on Avalere's analysis, tells a simple story: The states that embraced Obamacare and expanded Medicaid take a major hit; the states that obstructed it are the winners.

One other thing. You know why the map goes deep red in 2036? Because Graham-Cassidy's funding expires in 2026. States will be making plans on the hope and promise that the money will be reauthorized then, which the bill's sponsors pledge it will be. Otherwise, nobody wins.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • “Senate girds for final Obamacare repeal vote”: “The Senate will vote next week on the latest bill to repeal Obamacare — but the outcome is anything but certain. Senate Majority Leader Mitch McConnell (R-Ky.) plans to put a bill written by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) to a vote, hoping that a looming Sept. 30 deadline to pass the bill with just 50 votes will create enough pressure to finally pass a repeal of the health care law, his office said.” —Burgess Everett and Seung Min Kim, Politico
  • Senate Dem: GOP trying to 'purchase votes' for ObamaCare repeal bill with Alaska changes”: “Sen. Chris Murphy (D-Conn.) on Thursday slammed Republicans for reportedly offering to make changes to their ObamaCare repeal bill that would benefit Alaska to win support from Sen. Lisa Murkowski (R-Alaska).” —Julia Manchester, the Hill
  • “Medicaid directors oppose Graham-Cassidy Obamacare overhaul”: “State Medicaid directors are opposing a Republican Obamacare overhaul bill that would greatly restructure the federal-state healthcare program for the poor in their jurisdictions. The National Association of Medicaid Directors said Thursday that the bill would impose significant challenges to states, chiefly that they would shoulder too much risk under the legislation.” —Robert King, Washington Examiner

Analysis and longer reads

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