Vox - Obamacare repeal: Graham-Cassidy health care bill gains tractionhttps://cdn.vox-cdn.com/community_logos/52517/voxv.png2017-11-20T11:21:20-05:00http://www.vox.com/rss/stream/139432992017-11-20T11:21:20-05:002017-11-20T11:21:20-05:00Republicans can repeal Obamacare. They can’t repeal the logic of health insurance.
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<img alt="Woman holds up a cast with words "I 'heart' Obamacare"" src="https://cdn.vox-cdn.com/thumbor/y-WtdG2R2RRfYlc0vvhgp8EsywM=/4x0:4252x3186/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/51971813/GettyImages_186345396.0.jpeg" />
<figcaption>An Obamacare enthusiast | Jewel Samad / Getty</figcaption>
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<p id="51jdM5"><em>Uwe Reinhardt, a noted health-care economist at Princeton, died Nov. 13. Vox’s Sarah Kliff recently </em><a href="https://www.vox.com/health-care/2017/11/17/16671450/uwe-reinhardt-taught-me-health-care"><em>wrote</em></a><em> about how Reinhardt’s thinking has shaped her own coverage of health-care policy. A year ago, soon after Trump’s election, Reinhardt explained in Vox how the Republicans seemed inclined to ignore the fundamental challenge that health-care policy must confront: A very few sick people are responsible for most of the cost yet cannot afford to bear it themselves. </em></p>
<p id="1L39xX"><em>His skepticism about the political chances of ACA repeal, and his doubts that repeal could occur without potentially causing millions to lose their health insurance, proved prescient. The piece appears here in its original form:</em></p>
<p id="pdaj3q">President-elect Donald Trump was very explicit during the presidential campaign that one of his first acts in office would be to initiate the complete <a href="http://www.vox.com/2017/1/5/14179258/obamacare-repeal-republican-votes-trump">repeal of the Affordable Care Act</a> — something Republican Congress has been itching to do for years.</p>
<p id="2t51j5">Repealing Obamacare, however, with neither eliminate nor bypass the central challenge of health care, which can be gleaned from the chart below. That challenge will persist regardless of whether the Republicans quickly settle on an alternative plan, or if they repeal without a replacement.</p>
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<img alt="A chart showing the distribution of health care costs -- from those who use the least health care, to the top 10 percent." data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/78CVYNcqKUYN0cVmd0xWgaQ6B3U=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/7520249/uwe.one.png">
<figcaption><em> Adapted from Julie Schoenman, National Institute for Health Care Management, 2016</em></figcaption>
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<p id="b6Ju2z">Shown on the horizontal axis are deciles of the US population, arrayed from individuals with low per-capita spending on the left to high spending on the right. The vertical axis shows the percentage of total national health spending accounted for by a particular decile on the horizontal axis. In addition to the deciles, the most expensive 5 and 1 percent of the population are shown on the right. </p>
<p id="HrOWmT">Included in the high-cost segment of this graph will be individuals who may be only temporarily sick — for example, as a result of an accident. For the most part, however, they represent chronically ill people, often with multiple conditions that can be medically treated, albeit at great expense that exceeds these individuals’ capacity to finance their care with their own financial resources.</p>
<p id="nO8uTt">The fundamental questions in the US, as in other countries, are a) what kind of treatments these very sick members of society should receive, especially end-of-life treatments, and b) how those treatments should be financed, given that these treatments can quickly exhaust the budgets of the afflicted.</p>
<p id="LTv4QS">In very poor, developing countries the answer to this question may well have to be to leave those sick people to their own fate. That approach is unacceptable in the more developed world, where sick individuals usually do receive needed treatments even if they cannot pay for them.<strong> </strong>This leaves three alternative outside sources of financing that care, to wit: </p>
<ol>
<li id="cULtan">public subsidies financed from general taxation, </li>
<li id="hjOqSJ">cross-subsidies baked into health insurance premiums, forcing healthier individuals to subsidize through the premiums they pay the health care of chronically sicker member in the same insurance risk pool, or</li>
<li id="SFc5IY">cross-subsidies baked into the prices charged paying patients by doctors, hospitals and other providers of health care, which forces paying patients to cover these providers’ so-called “uncompensated care.” Paying patients include both insured patients and self-paying patients. </li>
</ol>
<p id="iEHMdk">All health insurance systems in the developed world use one or the other of these approaches to respond to the plight of very sick members of society. </p>
<p id="bNbEJj">Canada, for example, uses the first of these approaches, financing its single-payer provincial health plans mainly out of general taxation. </p>
<p id="fxzw3C">Germany relies on the second approach, using the premium mechanism to trigger the needed cross subsidies. The premiums paid by individual employees or retired persons have long been solely a fraction of the individual’s income. Thus they automatically embody cross subsidies from healthy to sick individuals and from high-income to low-income persons. </p>
<h3 id="uIMsfE">The unique US system combines all three ways of subsidizing care</h3>
<p id="5fqPlV">The highly pluralistic health insurance system of the US uses a mixture of all three approaches. Public programs such as Medicare, Medicaid, the VA health system and Tricare (the health insurance programs of families of active military personnel), rely mainly on taxation as a source of financing. </p>
<p id="rtIWbg">The far flung employment-based private health insurance system, on the other hand, which covers about two-thirds of the population and accounts for one-third of total national health spending, uses mainly the premium mechanism to subsidize the very sick. In that system, the individual employee’s contribution toward the premium for his or her health insurance is divorced from that individual’s health status; it is, in the jargon, community rated, meaning younger or healthier employees cross-subsidize the care of their sicker colleagues.</p>
<p id="PuroYg">Finally, the nation has always relied and continues to rely on an informal catastrophic health insurance system operated mainly by hospitals. Under this system, the cost of health care rendered to uninsured patients unable to pay for it is added to the prices charged insured or self-paying patients.</p>
<p id="8NR2sr">The Affordable Care Act of 2010 (ACA) incorporates a judicious mixture of the first two approaches. Within age belts, health insurance premiums on the ACA market places are community rated; the individual’s premium is completely divorced from that individual’s health status. The law limits the differences among age groups, so that people over 64 pay no more than three times what 21-year-olds pay. (The insurance industry has long pleaded for an age-band ratio of at least five-to-one.).</p>
<p id="fmY0p0">That feature of the ACA naturally forces relatively healthy individuals to pay premiums in excess of their actuarially projected costs. And the excess is used by insurers to cross-subsidize the health care of sicker members of the risk pool whose premiums are below their actuarially expected costs. But individuals up to 400 percent of poverty also receive direct, tax-financed federal subsidies toward the purchase of health insurance; individuals or families below 250 percent of the federal poverty level get, as well, direct federal subsidies towards out-of-pocket expenditures.</p>
<p id="0qZ0CD">The idea that individuals stricken with illness should not be punished by health-insurance premiums that reflect their dire health status probably appeals to many Americans — perhaps most, including president-elect Trump. It is, after all, the ethical foundation of the bulk of health insurance in the US. But implementing a policy that divorces premiums from the individual’s health status is very tricky when applied to the market for individually purchased insurance policies, as it is on the marketplace exchanges of the ACA. The graph below illustrates the problem. </p>
<h3 id="FnR19P">Some people will inevitably have to pay more than is “fair”</h3>
<p id="saY1iH">The graph represents an insurer’s risk pool of insured individuals who purchase health insurance individually and who are arrayed, on the horizontal axis, from relatively healthy on the left to relatively sick on the right. The vertical axis exhibits the premium charged individuals for a specified, insured benefit package. </p>
<p id="8Tmaeb">Prior to the onset of the ACA, insurers in this market would have based the premium charged the individual on that individual’s health status, a process called “medical underwriting.” Applicants had to complete very long detailed questionnaires on their own and on family members’ health status. The result was “actuarially fair” premiums — that is, premiums that reflect the projected cost of buying insured benefits for that individual. In the graph, these premiums are depicted by the upward-sloping white line.</p>
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<img alt=" " data-mask-text="false" src="https://cdn.vox-cdn.com/thumbor/sLC2NAIaq0YoHEhCF0G3zZ3IXM0=/800x0/filters:no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/7520269/uwe2.png">
<cite>Uwe Reinhardt</cite>
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<p id="5NcqNY">A switch from actuarially fair premiums to community-rated premiums that are divorced from the health status of individuals might result in the common premium represented by the light blue line in the graph. Relative to actuarially fair premiums, this switch would <em>raise</em> premiums for relatively healthy people who now are forced to cross-subsidize the health care of relatively sicker people. Those sicker people now pay a premium much below their actuarially fair premium. It is immediately obvious that such a switch presents a difficult political problem, because it redistributes income among the insured based on their health status.</p>
<p id="CzfRzb">If healthier people are free to decide whether or not to purchase health insurance, many of them might prefer to go uninsured rather than pay the community-rated premium. If so, the remaining risk pool of insured individuals will contain relatively more sick people, which will then raise the community-rated premium over this sicker risk pool from the blue line to, say, the dotted green line. This appears to have happened on the marketplace exchanges of the ACA, and is one major reason why premiums between 2016 and 2017 have risen by an average of 25 percent across the nation, albeit with a wide variance about that average. (In some areas premiums rose only by low single digits, in others by more than 100 percent.)</p>
<p id="pEVA35">Americans with insurance from the ACA marketplaces with incomes under 400 percent of the federal poverty level will not be affected by these high premium increases on the ACA exchanges. But the increase will seriously impact individuals with higher incomes and those who for one reason or another procure coverage <a href="http://acasignups.net/16/10/04/well-what-do-you-know-hhs-confirms-millions-exchange-enrollees-may-qualify-subsidies">apart from the ACA exchanges</a> and are therefore not entitled to federal subsidies (a group estimated to be about 7 million.)</p>
<h3 id="dT8vWy">The health insurance debate will be driven mostly by actuarial logic, not ideology</h3>
<p id="xPTztp">Because of this likely outcome of ever riskier insurance pools and the high premiums they trigger, nations that employ private health insurance coupled with community-rated premiums — for example, Germany, the Netherlands, and Switzerland — impose strictly enforced mandates on all individuals to purchase health insurance with a specified benefit package. </p>
<p id="e5EfDo">In principle, the ACA embodies such a mandate as well, but the penalty of disobeying it (an amount equal to 2.5 percent of income) is generally much lower than the premium for the mandated health insurance. Therefore, many healthier, younger individuals simply prefer to pay the penalty and go uninsured. That action then raises the community-rated premiums of the remaining, sicker insured. </p>
<p id="2ZmXp5">The important point to note is that the process described here is a purely an actuarial problem. If it is desired that: </p>
<ol>
<li id="Tl2Iau">everyone in society should have access to needed health care;</li>
<li id="2Qkfnt">no individual or family should be in financial distress as a result of medical bills;</li>
<li id="IGA3mX">the health insurance system employ private health insurers to implement the first two principles; and </li>
<li id="qXw4Nc">sicker people not be confronted with sky-high health insurance premiums or be refused coverage altogether, but instead pay community-rated premiums under guaranteed issue, </li>
</ol>
<p id="Z4ixqd">then such a system cannot long survive unless either everyone is mandated to buy insurance, or subsidies are provided through tax revenue to keep the premiums paid by individuals to some reasonable percentage of their income<strong>.</strong></p>
<p id="dKkBKz">That brings us to Trump, and his commitment to repeal the ACA. In this aim, the president-elect should be able to count on his Republican Congress, which has long stated a similar goal, and, in fact, has tried to do so, only to have its bill vetoed by President Obama. But there are two obstacles to Trump’s objective.</p>
<p id="m03Ry2">First, it would be very difficult to repeal the ACA in its entirety. That’s because the Senate, although in Republican hands, is not filibuster proof, which would require 60 Republican votes, which the Republicans don’t now have. The Senate could use a maneuver called “budget reconciliation” to get rid of any provision in the ACA that involves the flow of federal money — for example, the federal subsidies toward the purchase of health insurance on the exchanges. That could be achieved with only 51 votes. </p>
<p id="3WGjaM">But numerous other provisions, including the mandate to be insured, community rating, guaranteed issue (no denials for preexisting conditions) and many others, do not involve federal money and therefore cannot be eliminated through reconciliation. They are subject to a filibuster by Democrats. The problem for insurance companies is that the regulations on their industry would remain even as the subsidies for the purchasers of insurance disappeared.</p>
<p id="o0fZMV">Second, Republicans cannot get around the actuarial problem described above. Even if somehow they could eliminate guaranteed issue and community rating, they would face the problem of how to finance health care for the very sick segment of the population whose care exceeds their own resources. Just giving everybody a refundable tax credit as is proposed by Congress member Paul Ryan’s “A Better Way,” would not much help a very sick individual charged sky-high, actuarially fair premiums. </p>
<p id="5hS7pu">But unless these tax credits were tied closely to the health status of individuals, which is not part of the plan, they would do little to help such individuals. As Vox’s <a href="http://www.vox.com/2016/11/17/13626438/obamacare-replacement-plans-comparison">Sarah Kliff</a> <a href="http://www.vox.com/2016/11/17/13626438/obamacare-replacement-plans-comparison">points out</a>, Ryan’s proposal “makes insurance better for people who are young and healthy. It makes insurance worse for people who are old and sick.” </p>
<p id="PUv9Zu">At this time, it still remains every expert’s and pundit’s guess how a Trump administration and its Republican Congress would deal with the ethical and technical problems posed by a repeal of Obamacare. By itself, that move would yank affordable health insurance coverage away from about 20 million Americans who by now have gotten used to it. That does not seem a politically wise move. It would also deprive the health insurance industry, hospitals, physicians, and other providers of health care of revenue on which they have come to count. </p>
<p id="J2iCOw">Chances are, many components of the ACA would actually reappear under a Republican replacement for the ACA, perhaps rechristened as Trumpcare or Freedomcare or something like that. Recall that Obamacare basically rests on a 1990s vintage Republican chassis onto which Democrats fastened some additional policy particulars. </p>
<p id="46IztU">In any event, for observers with secure health insurance, it will be fascinating to watch how health reform will develop in 2017. For the less fortunate, however, it could be painful rather than, as Trump put it, “terrific.” </p>
<p id="sNu80M">The unfolding drama may seem to be driven largely by ideology and partisanship. In the end, however, there is no getting around the actuarial mathematics on which health insurance everywhere in the world rests — public as well as private. </p>
<p id="aerP7i">Unless, that is, our government is content to leave millions of Americans without the benefits of health insurance, and the access to essential health care it provides. </p>
<p id="pT8QA1">The presence of millions of citizens lacking health insurance remains a uniquely American problem.</p>
<p id="UpoYw2"><em>Uwe Reinhardt is the</em><em> James Madison</em><em> </em><em>p</em><em>rofessor of </em><em>p</em><em>olitical </em><em>e</em><em>conomy at Princeton University</em><em>.</em></p>
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<p id="brenRH"><a href="http://vox.com/the-big-idea">The Big Idea</a> is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at <a href="mailto:thebigidea@vox.com">thebigidea@vox.com</a></p>
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https://www.vox.com/the-big-idea/2016/11/23/13719388/obamacare-health-insurance-repeal-trumpUwe Reinhardt2017-09-27T09:00:02-04:002017-09-27T09:00:02-04:00Obamacare repeal isn’t dead as long as Republicans control Congress
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<img alt="Graham-Cassidy Healthcare Bill In Jeopardy As Senate Lacks Votes" src="https://cdn.vox-cdn.com/thumbor/PfkGf1G6r9SBa3m0ufC7eUb1nQ8=/0x0:3000x2250/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/56866547/854087682.0.jpg" />
<figcaption>Photo by Win McNamee/Getty Images</figcaption>
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<p>Republicans have lost a battle. They’re not done fighting the war. </p> <p id="y8eOPU">The latest Republican bill to repeal the Affordable Care Act died in the Senate on Tuesday. But the party’s effort to repeal the law remains very much alive. </p>
<p id="Uc7VL3">As long as the GOP controls Congress, they’ll keep trying.</p>
<p id="YHXrcQ">“We are going to fulfill our promise to repeal and replace,” Sen. Lindsey Graham (R-SC) promised at a press conference <a href="https://www.vox.com/2017/9/26/16368708/graham-cassidy-vote-canceled">announcing</a> there would be no vote on his proposal with Sen. Bill Cassidy (R-LA).</p>
<p id="NL4Gov">Already, Republicans are discussing how to overcome procedural hurdles to getting it done with just a simple majority, <a href="http://www.politico.com/story/2017/09/25/obamacare-repeal-republicans-budget-243125">Politico reports</a>. One aide said they’ve got their eye on a must-pass budget proposal. “It’s not like we couldn’t slip it in anyway,” the aide told Politico. </p>
<p id="ibvpna">The last few bills Republicans have tried, and failed, to pass were wildly unpopular, rejected by health care groups and scored poorly by the Congressional Budget Office. Still, the party believes that it must make good on its seven-year promise to repeal the law. Republican voters say it’s a priority, and <a href="https://www.vox.com/policy-and-politics/2017/9/25/16339336/graham-cassidy-republican-donors">donors do too</a>. </p>
<h3 id="Xysz9a">Republican legislators <em>want </em>to vote for a bill to repeal Obamacare</h3>
<p id="qL9Z6b">Consider, for a moment, all the things that <em>didn’t </em>deter Republican senators from continuing to pursue Obamacare repeal.</p>
<p id="kiHdRb">Republicans didn’t stop working on Obamacare repeal after House Speaker Paul Ryan declared it “the law of the land,” when the House couldn’t muster enough votes for a bill offered in March.</p>
<p id="KX5UyP">Republicans didn’t stop working on Obamacare repeal when they learned that the House bill, the American Health Care Act, would cause 22 million Americans to lose coverage. </p>
<p id="nssOqb">Republicans didn’t stop working on Obamacare repeal this past summer, after the Senate rejected three separate Obamacare repeal bills within the course of three days. </p>
<p id="ONxPXq">They didn’t stop working on repeal as patient group after patient group came out in opposition to their bills — or after all 50 Medicaid directors, including 33 who serve Republican governors, came out against the latest bill, Graham-Cassidy.</p>
<p id="2k62Pl">Republicans have continued to pursue Obamacare repeal despite opposition and poor polling numbers. Rank-and-file members have continued to agitate for Obamacare repeal even after leadership seemed to want to put it to rest. </p>
<p id="N3mpwL">Failed votes haven’t dampened the enthusiasm for Obamacare repeal in the past. So far, we’ve typically watched a cycle where Republicans take a month or two to regroup, and then begin to work anew on a slightly different plan. There is little reason to think this failed vote won’t lead to the same outcome. </p>
<h3 id="uc96fB">The Republican base still wants to see the Affordable Care Act turned back</h3>
<p id="Zq15Yu">Republicans have good political reasons to pursue repeal, even if their policy proposals aren’t holding up well.</p>
<p id="uw56G5">Last week, the Kaiser Family Foundation released a poll that asked 1,179 adults what they thought Congress ought to focus on for the remainder of 2017. </p>
<p id="eRiHFF">Seventy-one percent of those who identified as Republican said it was “extremely” or “very” important that Congress continue to focus on repealing the Affordable Care Act. </p>
<p id="QzWjjy">When the question was phrased as a choice — should Congress work to stabilize the Affordable Care Act or repeal it? — the results looked pretty similar. Two-thirds of Republicans would prefer to focus on getting rid of Obamacare rather than fixing it.</p>
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<p id="UbgKxL">The individual Obamacare repeal bills tend to poll poorly; a minority of Republicans supported the Graham-Cassidy plan. But more generally, the idea of repealing Obamacare still has valence among conservative voters. </p>
<p id="rfqjtI">This is something I understood a bit better after my reporting last fall in Kentucky, talking to Obamacare enrollees who voted for President Trump. Many of them did have real problems with their coverage. They were especially frustrated with how high their deductibles had grown, regularly upward of $2,000 or $3,000.</p>
<p id="90dXsI">The idea of “Obamacare repeal,” in their minds, represented a plan to fix those problems. None of the Republican plans offered so far actually deliver on that kind of fix. They would make the problem of high out-of-pocket spending significantly worse. But the idea that there is something broken in the health care system, and Republican legislators ought to fix it, seems to be at the heart of the desire for the party to keep on working towards repeal. </p>
<h3 id="yEn8ue">Obamacare repeal is still a live possibility</h3>
<p id="oehJ1U">Republicans control Congress for another year, at minimum. They have different vehicles they could use to pursue another push for Obamacare repeal, must-pass legislation that could become a new way forward.</p>
<p id="wKjQ9S">There are generally 45 or so Republicans who have shown themselves to be willing to vote for any Obamacare repeal bill. It’s been the handful of final votes from the caucus’s moderate and conservative wings that has sunk every previous plan.</p>
<p id="I20T0x">Those obstacles still remain: We still have not seen Sens. Susan Collin (R-ME) or Lisa Murkowski (R-AK) support a single repeal bill through this whole effort. Then again, they’ve often been reticent to oppose them up until the last minute — Murkowski still hasn’t come out against Graham-Cassidy, even after the decision not to hold a vote.</p>
<p id="2Vz5kA">This is no doubt an obstacle but, in my view, not an immovable one. One thing I’ll be watching closely is how the Trump administration manages the Affordable Care Act. In about a month, it will begin its first open enrollment season. So far, it has taken steps that will hurt the marketplaces, slashing the advertising budget by 90 percent and in-person assistance by 40 percent.</p>
<p id="s06dvM">Premiums will be higher in 2018 because the Trump administration has waffled on whether to make key payments.</p>
<p id="1Ey7Cy">If the marketplace ends this enrollment period in bad shape, that could change the dynamic in 2018. It could make the case for repeal stronger if the Affordable Care Act seems to be in dire straits. </p>
<p id="Ip9qCF">Republicans lost an Obamacare battle on Tuesday. But right now, all evidence suggests they are not ready to stop fighting the war.</p>
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<h3 id="Pzq5Bu">Join the conversation</h3>
<p id="8yVQBB">Are you an Obamacare enrollee interested in what happens next? Join our <a href="http://bit.ly/obamacare-vox"><strong>Facebook community</strong></a> for conversation and updates.</p>
https://www.vox.com/policy-and-politics/2017/9/27/16361270/obamacare-repeal-gopSarah Kliff2017-09-26T14:35:37-04:002017-09-26T14:35:37-04:00Republicans will not vote on Graham-Cassidy — admitting defeat on Obamacare repeal again
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<figcaption>Luke William Pasley/Pacific Press/LightRocket via Getty</figcaption>
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<p>This means they’ll miss a September 30 deadline for action. But it doesn’t kill repeal for good.</p> <p id="dCuSJR">Senate Republicans have admitted defeat on Obamacare repeal — again.</p>
<p id="ODGziP">Majority Leader Mitch McConnell announced Tuesday afternoon that he will not bring the Graham-Cassidy bill — the latest GOP repeal bill, which had gained steam this month — to a vote this week.</p>
<p id="r4edOl">With every Senate Democrat opposed to the bill, the publicly announced opposition of three Senate Republicans — Rand Paul (KY), John McCain (AZ), and Susan Collins (ME) — was enough to ensure it was headed for defeat.</p>
<p id="mQX7oa">So rather than force vulnerable senators to take another politically damaging vote certain to end in failure, McConnell has decided not to hold the vote at all.</p>
<p id="RS3qGS">“We don’t have the votes,” Sen. Bill Cassidy (R-LA), a co-author of the bill, said at a press conference Tuesday. “And since we don’t have the votes, we will postpone that vote.”</p>
<p id="k6SXA0">Sen. Lindsey Graham (R-SC), the other co-author, was publicly optimistic and asserted that his bill would pass eventually. “We’re coming back to this after taxes,” he said.</p>
<p id="z9gU4A">But the cancellation of this week’s vote has major implications. That’s because on Saturday, <a href="https://www.vox.com/policy-and-politics/2017/9/26/16361250/obamacare-repeal-deadline-september-30">September 30</a>, Congress’s current “budget reconciliation” instructions, which set up the special process that lets the Senate advance a bill with a simple majority rather than 60 votes, are set to expire. </p>
<p id="0y6nVA">Republicans believe the filibuster-proof budget reconciliation process is their only shot at passing major, transformative legislation. And after this Saturday, they’ll have officially squandered their first opportunity to use it, and to deliver on their longtime campaign promise of repealing President Obama’s signature legislative achievement.</p>
<p id="94KoCX">As <a href="https://www.vox.com/policy-and-politics/2017/9/26/16361250/obamacare-repeal-deadline-september-30">I wrote earlier today</a>, this doesn’t necessarily mean the end of the GOP’s Obamacare repeal efforts entirely, because the party could conceivably set up the reconciliation process again later on in this Congress.</p>
<p id="603FEf">But for now, Republican leaders appear to be putting health care to the side. “Where we go from here is tax reform,” McConnell said.</p>
<p id="a2wCDP">The party’s very next step is that they will have to pass a budget resolution, to set up that special 51-vote reconciliation process again. There had been some discussion among Senate Republicans about writing that resolution so that health legislation could be done together with tax reform through reconciliation. </p>
<p id="NT8cKn">That appeared to be technically possible, but many Republicans feared that tying their unpopular health legislation to a major tax bill could just end up dooming both to defeat. And in the end, comments from McConnell and Graham today suggest that they have decided against doing so.</p>
<p id="vtgtHW">So long as Republicans control Congress, Obamacare repeal <a href="https://www.vox.com/policy-and-politics/2017/9/26/16361250/obamacare-repeal-deadline-september-30">won’t ever truly be dead</a>. They’ll have options to potentially revive it later on, should the political situation change in their favor. For now, though, it will be put aside.</p>
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<h3 id="Pzq5Bu">Join the conversation</h3>
<p id="8ligSh">Are you an Obamacare enrollee interested in what happens next? Join our <a href="http://bit.ly/obamacare-vox"><strong>Facebook community</strong></a> for conversation and updates.</p>
https://www.vox.com/2017/9/26/16368708/graham-cassidy-vote-canceledAndrew Prokop2017-09-25T18:35:02-04:002017-09-25T18:35:02-04:00Susan Collins opposes Graham-Cassidy, and Obamacare repeal looks dead
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<figcaption>Washington Post / Getty Images</figcaption>
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<p>Three Republican senators oppose it — the magic number.</p> <p id="xlujLF">Sen. Susan Collins (R-ME) said Monday she opposes the Graham-Cassidy bill to repeal and replace Obamacare, likely the final blow to the legislation unless one of its opponents unexpectedly changes his or her mind.</p>
<p id="36Yxp4">Collins joins Sens. John McCain (R-AZ) and Rand Paul (R-KY) in opposing the bill. Because 50 of the 52 Senate Republicans must support Graham-Cassidy for it to pass, those three votes would be enough to kill it.</p>
<p id="awHwRy">“Health care is a deeply personal, complex issue that affects every single one of us and one-sixth of the American economy,” Collins said in a statement. “Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target.”</p>
<p id="3Yq80b">Collins cited three concerns with the bill, which would turn much of Obamacare’s funding into a block grant while also overhauling Medicaid:</p>
<ul>
<li id="nHHpML">The Medicaid cuts</li>
<li id="7BbvM6">The rollback of protections for people with preexisting conditions</li>
<li id="ahOucd">The opposition of various health care groups, which said the bill would lead to higher premiums and millions fewer people having health coverage</li>
</ul>
<p id="68KQvr">Collins was long suspected to be a “no” — she opposed all previous attempts this year to repeal the health law — but she made it official after the Congressional Budget Office released a preliminary analysis that said millions fewer Americans would have health insurance under Graham-Cassidy.</p>
<p id="MbOTob">All three Republican dissenters are objecting for different reasons:</p>
<p id="vGvolS">McCain objects to the rushed process that produced the bill and wants to return to bipartisan legislating on health care. His position is almost certainly not going to change. </p>
<p id="kfMv6i">Paul has opposed the plan because, he argues, it keeps too much of Obamacare and creates a new Republican spending program. The Kentucky senator has argued that Republicans should either fully repeal the law with no replacement or focus on only repealing the parts of the law on which Republicans broadly agree, like the “skinny” repeal bill that got 49 votes in late July.</p>
<p id="YmEllG">While Paul has left the door open to negotiating on Graham-Cassidy, his demands include eliminating the block grant program at the heart of the bill. So his opposition also looks entrenched, barring a remarkable reversal.</p>
<p id="Z0nPlh">Not only would Senate leaders need to convert a current opponent to pass Graham-Cassidy, but other holdouts — like Sen. Lisa Murkowski (R-AK) and Ted Cruz (R-TX) — would also need to come around to get to 50 votes. The path looks impossibly long, with only a few days left for unlikely flip-flops and for skeptics to be won over.</p>
<p id="YgXzXy">Senate Republicans still have until September 30 to pass the bill using the current “budget reconciliation” privileges that allow it to pass with only a bare majority. After that, they would have to at the very least pass a new budget resolution to restart the process.</p>
<p id="TpAqVR">Collins’s full statement is below.</p>
<hr class="p-entry-hr" id="aic6jc">
<p id="7H07WU">Health care is a deeply personal, complex issue that affects every single one of us and one-sixth of the American economy. Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target. Today, we find out that there is now a fourth version of the Graham-Cassidy proposal, which is as deeply flawed as the previous iterations. The fact that a new version of this bill was released the very week we are supposed to vote compounds the problem.</p>
<p id="pgcoIE">I have three major concerns with both the proposal that we were discussing last week and the newest version that was put together this weekend:</p>
<p id="KOREsU">First, both proposals make sweeping changes and cuts in the Medicaid program. Expert projections show that more than $1 trillion would be taken out of the Medicaid program between the years 2020 and 2036. This would have a devastating impact to a program that has been on the books for 50 years and provides health care to our most vulnerable citizens, including disabled children and low-income seniors.</p>
<p id="oodvli">Second, both bills open the door for states to weaken protections for people with pre-existing conditions, such as asthma, cancer, heart disease, arthritis, and diabetes. Some states could allow higher premiums for individuals with pre-existing conditions, potentially making their insurance unaffordable. States could also limit specific categories of benefits for Affordable Care Act policies, such as eliminating coverage for mental health or substance abuse treatment.</p>
<p id="VeYGHo">Third, physicians, patient advocates, insurers, and hospitals agree that both versions of this legislation would lead to higher premiums and reduced coverage for tens of millions of Americans.</p>
<p id="jazmhq">The CBO’s analysis on the earlier version of the bill, incomplete though it is due to time constraints, confirms that this bill will have a substantially negative impact on the number of people covered by insurance.</p>
<p id="Y21n5S">There has been some discussion that the new version of the bill includes additional money for my home state of Maine. The fact is, Maine still loses money under whichever version of the Graham-Cassidy bill we consider because the bills use what could be described as a “give with one hand, take with the other” distribution model. Huge Medicaid cuts down the road more than offset any short-term influx of money. But even more important, if Senators can adjust a funding formula over a weekend to help a single state, they could just as easily adjust that formula in the future to hurt that state. This is simply not the way that we should be approaching an important and complex issue that must be handled thoughtfully and fairly for all Americans.</p>
<p id="guwPnB">The Affordable Care Act has many flaws that need to be addressed. The current state of health insurance, where premiums are skyrocketing, choices are limited, and small businesses are struggling, needs fixing. My focus will remain on remedying these problems.</p>
<hr class="p-entry-hr" id="YkYUEn">
<h3 id="Pzq5Bu">Join the conversation</h3>
<p id="cfxc83">Are you an Obamacare enrollee interested in what happens next? Join our <a href="http://bit.ly/obamacare-vox"><strong>Facebook community</strong></a> for conversation and updates.</p>
https://www.vox.com/policy-and-politics/2017/9/25/16364020/susan-collins-graham-cassidy-opposesDylan Scott2017-09-25T18:10:01-04:002017-09-25T18:10:01-04:00CBO: Graham-Cassidy would lead to “millions” fewer people with insurance
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<figcaption>Alex Wong / Getty Images</figcaption>
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<p>It’s an incomplete analysis, but it aligns with outside estimates.</p> <p id="kOtoCq">The Graham-Cassidy plan to repeal and replace Obamacare would reduce the federal deficit by at least $133 billion, the Congressional Budget Office estimated Monday afternoon, after reviewing a recent not final version of the bill.</p>
<p id="WK09Kh">While the office couldn’t specify a number, it also said that the bill would likely lead to millions fewer Americans having health insurance when compared with current law.</p>
<p id="RyTUOG">“The number of people with comprehensive health insurance that covers high-cost medical events would be reduced by millions,” when compared with Obamacare, the CBO’s analysts <a href="https://www.cbo.gov/publication/53126">said</a>.</p>
<p id="7XDBik">The coverage losses would result from Medicaid cuts, cuts to tax subsidies for people to purchase private insurance, and the repeal of Obamacare’s individual mandate, the CBO said.</p>
<p id="iwYkpW">But that’s about as specific as the office could be. </p>
<p id="kqLALL">The CBO has said it will take weeks to fully assess the plan, including exactly how many people would have health insurance under the bill or what would happen to insurance premiums. </p>
<p id="XzCVCf">But we do have more specific outside estimates on the previous version of the bill: upward of 20 million fewer Americans with health insurance and hundreds of billions of dollars in cuts to federal health care spending.</p>
<p id="Qkg2Le">Meanwhile, a vote on the bill is just days away, and the Senate is still revising it. Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA) released a new draft Monday. The topline numbers from the CBO are unlikely to change, however.</p>
<p id="2zOYlv">The deficit reduction number is important for procedural reasons. Under the budget reconciliation process Senate Republicans are using to pass their Obamacare repeal bill with 51 votes instead of the usual 60, the Senate’s health care legislation must save as much money as a House version passed in May — a little more than $100 billion over 10 years. </p>
<p id="cgMeFr">Senate Republicans will still likely need to get their final version of the bill reviewed by the CBO, at least to double-check that the final bill meets the reconciliation requirements. And it’s not clear if they’ll wait for the full analysis of the effect on premiums and the number of people with insurance in order to hold a vote.<strong> </strong></p>
<h3 id="TQBuCb">Graham-Cassidy’s projected coverage losses: 21 million</h3>
<p id="AE863X">Although the CBO is still doing its calculations, we have some <a href="https://www.brookings.edu/research/how-will-the-graham-cassidy-proposal-affect-the-number-of-people-with-health-insurance-coverage/">estimates</a> of the original bill from the USC-Brookings Schaeffer Initiative for Health Policy, which attempted to replicate the CBO’s methodology:</p>
<ul>
<li id="fynYeu">15 million fewer people with insurance in 2018 and 2019, versus current law</li>
<li id="VkXUgu">21 million fewer insured by 2026</li>
<li id="qwyfv0">32 million fewer Americans with coverage after 2026 if the funding provided in the Graham-Cassidy bill is not reauthorized by Congress</li>
</ul>
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<p id="rcRBin">The analysis may be the best estimates the public and Republican senators will see before they vote on the Graham-Cassidy plan, which would turn much of Obamacare’s funding into a block grant and send the money to states to establish their own health care programs.</p>
<h3 id="TIGm7T">Graham-Cassidy’s projected funding cuts: $215 billion by 2026</h3>
<p id="o7G47N">An <a href="http://avalere.com/expertise/managed-care/insights/graham-cassidy-heller-johnson-bill-would-reduce-federal-funding-to-sta"><strong>analysis</strong></a> from Avalere Health, an independent consulting firm, put a price tag on the original bill’s spending cuts: $215 billion from 2020 to 2026, when the bill’s funding expires. Stretched out to 2036, if the spending isn’t reauthorized, the cuts are nearly $4 trillion versus current law.</p>
<p id="1wdfzy">The crux of Graham-Cassidy is a block grant program: The bill keeps most of Obamacare’s taxes and packages the revenue into block grants that are sent down to the states to set up their own health care programs with few strings attached. A complex formula, based in part on the number of residents in or near poverty, is used to distribute the funding between the states. The bill also overhauls Medicaid, placing a federal spending cap on the program for the first time.</p>
<p id="41R7Kh">Add it all up and, generally speaking, states led by Democrats are hit the hardest, while states led by Republicans receive the largest reward.</p>
<p id="i2NaTj">Or looked at another way, because the cuts don’t break down purely along party lines: The more aggressively a state implemented Obamacare and sought to enroll people in coverage, the worse it fares under Graham-Cassidy.</p>
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<cite><a href="http://voxcom.createsend1.com/t/d-l-uyitykd-l-m/">Javier Zarracina / Vox</a></cite>
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<p id="5CySjP">The last-minute revisions that Graham and Cassidy are making don’t seem likely to significantly change that underlying story. But the bill is being rushed to the Senate floor too fast for the CBO to confirm what outside estimates have said.</p>
<hr class="p-entry-hr" id="AiuDJq">
<h3 id="Pzq5Bu">Join the conversation</h3>
<p id="uMSpOQ">Are you an Obamacare enrollee interested in what happens next? Join our <a href="http://bit.ly/obamacare-vox"><strong>Facebook community</strong></a> for conversation and updates.</p>
https://www.vox.com/policy-and-politics/2017/9/25/16361380/graham-cassidy-cbo-score-lol-watDylan Scott2017-09-25T15:40:01-04:002017-09-25T15:40:01-04:00Graham-Cassidy would let insurers drop birth control coverage
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<img alt="Protesters oppose Rep. Carlos Curbelo’s vote to repeal the Affordable Care Act in Miami in August 2017" src="https://cdn.vox-cdn.com/thumbor/AQ83X54b6dClQKGdCz63-om7RT0=/0x0:3000x2250/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/56846073/826024724.0.jpg" />
<figcaption>Protesters oppose Rep. Carlos Curbelo’s vote to repeal the Affordable Care Act in Miami in August 2017. | Photo by Joe Raedle/Getty Images</figcaption>
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<p>The new version of the bill goes even further than its predecessor in rolling back protections for contraceptive coverage.</p> <p id="dOqovY">The health care bill sponsored by Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA) was already the most sweeping of any Obamacare repeal effort in its restrictions on <a href="https://www.vox.com/policy-and-politics/2017/9/19/16328928/obamacare-repeal-cassidy-graham-health-care-women">reproductive health coverage</a>. A new version <a href="https://www.vox.com/policy-and-politics/2017/9/25/16360550/graham-cassidy-revised-explained">released on Sunday night</a> would go even further than its predecessor in rolling back protections that have allowed millions of Americans to get affordable birth control. </p>
<p id="Lxvs4v">This version would give states even more leeway to bypass the requirements of Obamacare — including those that guarantee coverage for contraception. In so doing, it may please conservatives who want states to have greater say over what is covered, and those who have opposed the contraceptive requirements from the beginning. But it will also threaten a benefit on which many people rely to maintain their health and plan their families.</p>
<h3 id="ul1oqq">Starting in 2020, states can make their own rules when it comes to coverage</h3>
<p id="jBoBVv">Allowing insurance plans to cover less has been one focus of the Obamacare repeal effort. As of last week, Graham-Cassidy accomplished this by letting states seek waivers<strong> </strong>from some of Obamacare’s requirements. States that received waivers could allow insurers to sell bare-bones policies that didn’t cover everything required under Obamacare. </p>
<p id="AGFCPc">Under the <a href="https://www.vox.com/policy-and-politics/2017/9/25/16360550/graham-cassidy-revised-explained">new version released Sunday night</a>, however, states don’t even have to get waivers, said Adam Sonfield, senior policy manager at the Guttmacher Institute. They can simply set their own rules about what insurance plans have to cover. </p>
<p id="IwBmfc">The new bill is also explicit about which provisions states can override, Sonfield said. These include the <a href="https://www.healthcare.gov/coverage/what-marketplace-plans-cover/">essential health benefits requirements</a> for individual and small-business plans, which include birth control coverage as well as maternity care and prescription drug coverage. States could also choose whether to override the<strong> </strong>preventive services requirement under which most private plans have to cover birth control with no cost sharing. More than 55 million women have copay-free coverage of birth control under this requirement, according the <a href="https://aspe.hhs.gov/system/files/pdf/139221/The%20Affordable%20Care%20Act%20is%20Improving%20Access%20to%20Preventive%20Services%20for%20Millions%20of%20Americans.pdf">Department of Health and Human Services</a>.</p>
<p id="J9m7b1">The Trump administration is reportedly considering weakening the preventive services requirement in a different way, by <a href="https://www.vox.com/policy-and-politics/2017/5/31/15716778/trump-birth-control-regulation">offering an exception</a> to any employer that has a moral or religious objection to birth control coverage. Graham-Cassidy would go further by allowing states to lift the requirement entirely.</p>
<p id="noCmdq">All this would take effect in 2020, when Graham-Cassidy converts Obamacare’s tax credits and the Medicaid expansion into a system of <a href="https://www.vox.com/policy-and-politics/2017/9/6/16263316/cassidy-graham-mccain-obamacare-repeal">block grants for states</a>. </p>
<p id="vEZhTN">Gutting birth control coverage requirements could drive up costs for the millions of Americans who use contraception to prevent pregnancy while they <a href="https://www.guttmacher.org/gpr/2017/01/what-stake-federal-contraceptive-coverage-guarantee">finish school or look for a job</a> or to otherwise plan their reproductive lives, as well as those who need hormonal birth control to manage medical conditions like endometriosis. In particular, allowing states to get rid of the requirements would make it harder for Americans to afford the long-acting contraceptives that are most effective at preventing pregnancy. The out-of-pocket cost of an IUD, for instance, averages <a href="https://amino.com/blog/iud-cost/">around $1,000</a>.</p>
<p id="rwcTuc">The new version of Graham-Cassidy also leaves in place other provisions that have concerned reproductive health advocates, including <a href="https://www.vox.com/policy-and-politics/2017/9/19/16328928/obamacare-repeal-cassidy-graham-health-care-women">abortion restrictions</a> tied to the block grants and a provision to strip funding from Planned Parenthood. It also keeps a provision that would <a href="https://www.vox.com/policy-and-politics/2017/9/21/16340488/graham-cassidy-obamacare-health-care-abortion">ban abortion coverage</a> on the exchanges beginning in 2018, potentially causing chaos in many states.</p>
<p id="LpdPuq">The bill also includes some <a href="https://www.vox.com/policy-and-politics/2017/9/25/16360550/graham-cassidy-revised-explained">funding provisions that would benefit Alaska</a>, presumably in an effort to get the support of Sen. Lisa Murkowski (R-AK), who has voted against past repeal efforts. Sen. Murkowski has not yet taken a public stand on the bill. On Monday, four Planned Parenthood patients from Alaska sent her <a href="https://www.plannedparenthood.org/uploads/filer_public/d2/5b/d25b945d-d0aa-496a-98fd-7371404a3c1a/pp_patient_letter_to_sen_murkowski_on_graham-cassidy_1.pdf">a letter</a> asking her to vote no, arguing that the bill would harm women and families.</p>
<p id="JzBqRu">“We would like to ask you to stay strong for Alaskans,” they wrote.</p>
<hr class="p-entry-hr" id="PcSApn">
<h3 id="Pzq5Bu">Join the conversation</h3>
<p id="G0c9Nj">Are you an Obamacare enrollee interested in what happens next? Join our <a href="http://bit.ly/obamacare-vox"><strong>Facebook community</strong></a> for conversation and updates.</p>
https://www.vox.com/policy-and-politics/2017/9/25/16361392/graham-cassidy-health-care-obamacare-repeal-birth-controlAnna North2017-09-25T13:10:02-04:002017-09-25T13:10:02-04:00The resistance is making one last all-out push to kill the GOP health bill
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<figcaption>Kimberley Benyr, whose daughter died earlier this month of cancer, waits outside the hearing for Senate Republicans’ health care bill. (Jeff Stein/Vox)</figcaption>
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<p id="HHHjXN">More than 300 health care activists, disability rights advocates, and organizers gathered on second floor of the Dirksen Senate Office Building on Monday morning to oppose Senate Republicans’ Graham-Cassidy health care bill. </p>
<p id="MqbHwP">The bill would sharply reduce spending for Medicaid by billions of dollars by tying it to medical inflation, blow up Obamacare’s marketplaces, and open the door for states to curtail protections for patients with preexisting conditions.</p>
<p id="digSVQ">One person attending was Kimberley Benyr, whose 12-year-old daughter Madeleine died of liver cancer on September 12. Four rounds of chemotherapy had not been enough. Less than two weeks later, the former auto insurance salesperson flew by herself to Washington, DC. She’s here to remind senators that even though her daughter’s life couldn’t be saved, millions of others depend on the kind of care that could be stripped away should Graham-Cassidy become law.</p>
<p id="Xk6yhi">“Maddy didn’t make it, but there were hundreds of other children in that hospital who need Medicaid to have a chance,” said Benyr, 42, of Bella Vista, Arkansas, before showing her daughter’s death certificate to this reporter. “If you’re not on Medicaid and your child gets sick, you are in extreme danger [of medical bankruptcy] through no fault of your own.”</p>
<p id="UodYWr">The line of activists Monday morning snaked through four separate hallways and into the Hart Senate Office Building. The activists have arrived as Senate Republicans are furiously whipping to get their health care bill to 50 votes before the September 30 deadline. </p>
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<blockquote class="twitter-tweet">
<p lang="en" dir="ltr">The Graham-Cassidy hearing is the hottest ticket in town, in one video: <a href="https://t.co/y4prO1DA5C">pic.twitter.com/y4prO1DA5C</a></p>— Jeff Stein (@JStein_Vox) <a href="https://twitter.com/JStein_Vox/status/912317395972313089">September 25, 2017</a>
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<p id="DASeFF">But activists on the front line of the fight are planning a show of force that the Republican caucus can’t ignore. Even as Trump is tweeting about the NFL, health care advocates remain focused and are ready for what they hope is one final push to defeat Obamacare repeal. </p>
<h3 id="uNAuRg">The resistance is ready for yet another health care fight</h3>
<p id="rAfT93">Since the health care debate began, advocacy groups, liberal organizations, and “resistance” leaders have waged an all-out war against the GOP health care bill — staging sit-ins, clogging the airwaves, and organizing mass acts of civil disobedience across the country. Given that Republicans have full control of Congress, they say it’s been their only hope.</p>
<p id="WpEWZQ">“We want these staffers to feel as if they’re under siege from the rest of America, from a country that hates this bill,” said Murshed Zaheed, political director of the progressive advocacy group CREDO.</p>
<p id="kGRJeU">The purpose of the activism rests on the assumption that Republican senators may be responsive to public pressure. That may be a debatable premise, given that the Republican Senate got within one vote of passing a “skinny repeal” bill amid a wave of activism against the bill. But activists counter that Republicans initially planned on repealing Obamacare by last February and pinpoint the public pressure as the reason they’ve been delayed for so long.</p>
<p id="n5Wbts">“Every senator has a mental Richter scale in which they can measure the scale of the upheaval caused by any political movement. They look to a key set of signals for how destructive an earthquake is going to be,” <a href="https://www.vox.com/policy-and-politics/2017/6/26/15856894/resistance-obamacare-repeal-push"><strong>said</strong></a> Ben Wikler, Washington director of MoveOn.</p>
<p id="oEsr3h">The signs are again there that Republicans will risk a political earthquake by passing the bill. On Monday, a <a href="https://www.cbsnews.com/news/poll-graham-cassidy-republican-health-care-bill-repeal-replace-obamacare-aca/">new poll</a> came out showing that only about 25 percent of the public approves the Graham-Cassidy bill, <a href="https://www.vox.com/policy-and-politics/2017/9/22/16349470/polling-graham-cassidy-not-good">confirming an earlier finding by Public Policy Polling last week</a>. That bill showed that, contrary Sen. Bill Cassidy’s (R-LA) promises, only 20 percent of Americans think the GOP bill will result in more Americans gaining coverage.</p>
<p id="7g3jRa">Democrats have moved quickly to try to make Republicans feel the heat. One group, Save My Care, has launched six-figure ad campaigns in West Virginia, Alaska, and Maine urging moderate Republicans to oppose the bill. The organization <a href="https://www.youtube.com/watch?v=fesw9HLCmP0&feature=youtu.be">launched</a> another TV ad blitz on Monday highlighting that the bill is opposed by the American Medical Association, AARP, The American Cancer Society, and Medicaid directors in all 50 states.</p>
<div id="SFADao"><div style="left: 0; width: 100%; height: 0; position: relative; padding-bottom: 56.2493%;"><iframe src="https://www.youtube.com/embed/fesw9HLCmP0?rel=0&" style="border: 0; top: 0; left: 0; width: 100%; height: 100%; position: absolute;" allowfullscreen="" scrolling="no"></iframe></div></div>
<p id="opAWht">And then there’s the activism.</p>
<h3 id="hh79Hq">Adapt maintain the front lines of the fight against Graham-Cassidy</h3>
<p id="hia48g">Danny Saenz, 57, woke up at 2:30 am on Monday morning to begin sounding the alarm against the latest effort to repeal Obamacare. Saenz, who has cerebral palsy and uses a wheelchair, wore a bright yellow shirt proclaiming “MY MEDICAID MATTERS” as cries of “Kill the bill!” echoed around the Senate hallways.</p>
<p id="mwxsmT">“They’re trying to kill people with disabilities,” said Saenz, arguing that reducing Medicaid payments would wind up reducing the amount of home health care. “People have to pay attention. They’re trying to throw people off of Medicaid.”</p>
<p id="gySSzZ">Saenz is a member of Adapt, a national disability rights organization that fears Republicans’ proposed Medicaid cuts and has staged high-profile acts of civil disobedience in Republican Senate offices. Adapt activists have been on the front lines of the Obamacare repeal front since Republicans took control of Congress this January.</p>
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<blockquote class="twitter-tweet">
<p lang="en" dir="ltr">Eiryn Griest Schwartzman, 20, is studying public health at community college and in Medicaid. Woke up at 430 am to be here since 6 <a href="https://twitter.com/eiryngs">@eiryngs</a> <a href="https://t.co/PsAMkEFudK">pic.twitter.com/PsAMkEFudK</a></p>— Jeff Stein (@JStein_Vox) <a href="https://twitter.com/JStein_Vox/status/912345728785186816">September 25, 2017</a>
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<p id="rX5Heq">On Monday, they were joined primarily by what activists know as “Birddogging Nation” — primarily the activist groups Housing Works and the Center for Popular Democracy. (“Birddogging” is the practice of following around and badgering elected officials over a particular issue.) </p>
<p id="Oe9iu2">“The hundreds of people you see are trying to send the strongest message that they possibly can to senators that we do not want them to vote to take away our health care. Tens of millions of people around the country are counting on us,” said Jennifer Flynn Walker of CPD.</p>
<p id="EoXBi4">Then there’s Planned Parenthood, which was expected to bring activists into the Capitol on Monday as well. They planned on staging a press conference with two Democratic Senators — Sens. Patty Murray (D-WA) and Kirsten Gillibrand (D-NY) — near the hearing at around noon on Monday.</p>
<p id="tupst4">Benyr, the Arkansas woman whose daughter died earlier this month, planned on being in Dirksen through the hearing. As her daughter was dying, Benyr recalled, a nurse at the Little Rock Children’s Hospital approached her to discuss the Republicans’ attempts to repeal Obamacare. The nurse said she was worried that Republicans’ proposed Medicaid cuts would gut funding for children’s hospitals across the country.</p>
https://www.vox.com/policy-and-politics/2017/9/25/16360864/activists-graham-cassidy-health-careJeff Stein2017-09-25T12:00:05-04:002017-09-25T12:00:05-04:00Graham-Cassidy now guts Obamacare even more
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<img alt="Lindsey Graham Bill Cassidy" src="https://cdn.vox-cdn.com/thumbor/SJgwHUBIQpq8g3jhTcDQy5AKVZk=/0x0:6000x4500/1310x983/cdn.vox-cdn.com/uploads/chorus_image/image/56840657/GettyImages_850483118.0.jpg" />
<figcaption>The Washington Post / Getty Images</figcaption>
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<p>Senate Republicans are desperately hunting for votes for repeal.</p> <p id="uWzvRZ">Senate Republicans, seemingly short on votes for their last-ditch plan to repeal Obamacare, are desperately tweaking the bill in hopes of winning over both their moderate and conservative wings.</p>
<p id="DmQRRY">The result is a plan from Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-SC) that would go even further in rolling back Obamacare’s protections for people with preexisting conditions, while adding hundreds of millions of dollars meant to sweeten the deal for senators from key states.</p>
<p id="JJ6PCt">Graham-Cassidy would now, according to health policy experts, effectively end to Obamacare’s insurance protections. People with preexisting conditions could face higher premiums, insurers could choose which services to cover, and plans could also require people to pay more money out of pocket than Obamacare allows.</p>
<p id="9Zithn">The core of the latest version of the plan, released late Sunday night, is the same: Much of Obamacare’s funding would be converted into block grants that states could use to set up their own health care programs, while Medicaid would be fundamentally overhauled with a federal spending cap. </p>
<p id="QC4sjL">The result, according to estimates of the previous iteration, would be <a href="https://www.vox.com/policy-and-politics/2017/9/20/16338370/graham-cassidy-rewards-anti-obamacare-states">hundreds of billions of dollars</a> in federal spending cuts for health care and <a href="https://www.vox.com/policy-and-politics/2017/9/22/16350320/graham-cassidy-uninsured-brookings-usc-cbo">tens of millions</a> fewer Americans with health insurance, compared to Obamacare.</p>
<p id="YeKFOR">The bill has looked short of the votes to pass, with conservatives angry it doesn’t do more to roll back the 2010 health care law and moderates wary of the spending cuts. Sen. John McCain (R-AZ) wants a return to regular order and a bipartisan bill. Sen. Rand Paul (R-KY) says it keeps too much of Obamacare. Sen. Susan Collins (R-ME) has yet to see an Obamacare repeal bill she likes. There are more votes in doubt, and Republicans can lose only two of their 52 members and still pass a bill.</p>
<p id="XpKhox">So Graham and Cassidy are trying to pull their plan to the right and left at the same time: It would now gut Obamacare’s regulations almost entirely to try to win over conservatives, but it adds funding targeted to some specific states in an attempt to assuage moderate concerns.</p>
<p id="aueP8X">“The revised Graham-Cassidy bill is in effect federal deregulation of the insurance market,” Larry Levitt, senior vice president at the Kaiser Family Foundation, <a href="https://twitter.com/larry_levitt/status/912135675159314437">tweeted</a>.</p>
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<p lang="en" dir="ltr">If there was any question about Graham-Cassidy's removal of federal protections for pre-existing conditions, this new draft is quite clear.</p>— Larry Levitt (@larry_levitt) <a href="https://twitter.com/larry_levitt/status/912137843157303296">September 25, 2017</a>
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<p id="6vGZBQ">Those changes, paired with the remaining deep spending cuts in the bill, mean a dramatic undoing of the changes the health care law made that helped <a href="https://www.vox.com/policy-and-politics/2017/8/29/16223042/voxcare-record-insured-americans">bring</a> the uninsured rate to a historic low and dramatically <a href="https://qz.com/1043627/personal-bankruptcies-are-down-50-in-the-us-thanks-obamacare/">reduced</a> medical bankruptcies, while also bringing an end to Medicaid as it currently exists.</p>
<p id="9g0GM9">Yet despite the tinkering, Graham-Cassidy still might not have a majority in the Senate, even as Republicans push to put the bill on the Senate floor before September 30.</p>
<h3 id="u3jJ42">Graham-Cassidy now ends most of Obamacare’s insurance protections</h3>
<p id="1Os0e3">States would have wide latitude to rip up the insurance regulations that Obamacare instituted to protect people with preexisting conditions and limit the risks for medical bankruptcy under the new Graham-Cassidy, experts said.</p>
<p id="WF3ZWs">Obamacare prohibited insurers from charging sick people more than healthy people, required plans cover certain essential health benefits, and set rules for how generous insurance coverage must be and how much plans can ask customers to pay out of pocket. Under Graham-Cassidy, states would have very broad discretion to undermine or eliminate those rules.</p>
<p id="Fq44WH">The bill “amounts to launching a cannonball into the insurance pool and then claiming it won’t cause a splash or make anyone wet,” John Graves, a health policy professor at Vanderbilt University, told me. “This is a radical restructuring of the insurance market, with predictable consequences and probably an endless list of unintended consequences.”</p>
<p id="0Pa0ii">Under Obamacare, insurers had to sell the same insurance at the same price to everybody, with a federal requirement that people buy insurance meant to ensure that healthy people would buy plans. Graham-Cassidy, though, would allow states to split their insurance markets, and insurers could offer different plans at different prices to attract healthy people, who might prefer skimpier plans, and sick people, who need more comprehensive coverage.</p>
<p id="trjSYc">Experts had previously warned that breaking up the market that way would lead to skyrocketing costs for sicker people. Conservatives have argued it would be better to segment the market and then funnel federal money to help cover costs for people with a significant medical history, rather than requiring health plans to charge sick and healthy people the same amount, which increases costs for the latter group.</p>
<p id="gZirSj">The federal government would also have little oversight of how much states could undo Obamacare’s regulatory regime. The bill does require states to submit a plan, explaining how they would provide adequate and affordable coverage to people with preexisting conditions, but that is the extent of its requirements, experts say.</p>
<p id="k7qNX5">“The ‘shall’ in the state plan is that the state shall submit a plan,” David Anderson, who previously worked in the insurance industry and is now at Duke University, said. “It does not define what is needed in that plan or consequences or courses of action that can be taken if that plan fails to meet its objectives.”</p>
<h3 id="MLxZPc">The bill would cut federal health care spending and overhaul Medicaid</h3>
<p id="8fUBJr">Graham-Cassidy would repeal the funding Obamacare spent to expand health insurance coverage — tax credits for middle-income Americans, the cost-sharing reduction subsides for low-income Americans, and the Medicaid expansion in 2020. It replaces all those programs with a market-based health care grant program, which would send states a lump sum of money to put toward new health care programs that must be set up in the next two years.</p>
<p id="ovW0nI">Under Obamacare, this money has to be spent on providing health insurance. Under Graham-Cassidy, it can be spent on other things. States would be allowed to set up high-risk pools for people with high medical costs, they could pay providers directly for health care services, or they could help people buy insurance.</p>
<p id="EX4UtH">Through a complex funding formula — including things like population density, percentage of population in poverty, and other factors — the bill would divvy up this money between the states, which would then decide how to put it to work.</p>
<p id="0gNEVy">The result would be a net decrease to federal spending — $215 billion by 2026, according to <a href="https://www.vox.com/policy-and-politics/2017/9/20/16338370/graham-cassidy-rewards-anti-obamacare-states">one estimate</a> — with states that expanded Medicaid under Obamacare facing the deepest cuts and states that refused to do so seeing increased funding. The funding also expires after 2026 and would have to be reauthorized then. </p>
<p id="QmH7OT">Otherwise, the funding cuts would be catastrophic, removing hundreds of billions of dollars — trillions, eventually — from the US health care system.</p>
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<cite><a href="http://voxcom.createsend1.com/t/d-l-uyitykd-l-m/">Javier Zarracina / Vox</a></cite>
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<p id="81XDPK">Graham-Cassidy also fundamentally overhauls Medicaid, placing a federal spending cap on what had previously been an open-ended entitlement. That alone would <a href="https://www.vox.com/policy-and-politics/2017/9/21/16339524/republicans-obamacare-repeal-graham-cassidy-nobody-cares">slash</a> more than $100 billion in Medicaid spending in the next 10 years, according to independent estimates.</p>
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<cite>Javier Zarracina / Vox</cite>
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<h3 id="HoZl12">Republicans are getting desperate as they struggle to find the votes</h3>
<p id="cwd0nt">The original version of Graham-Cassidy lacked the votes to pass. Senate Republicans are using the “budget reconciliation” process to move the bill with 50 votes instead of the usual 60, but that still requires 50 of the 52 Republican senators to agree on a plan.</p>
<p id="B0K2Uz">They are also facing an important deadline: The current reconciliation privileges expire on September 30. After that, Senate Republicans would have to at the very least pass a new budget resolution to jump-start the repeal debate again.</p>
<p id="Em4zyE">The original version of Graham-Cassidy <a href="https://www.vox.com/policy-and-politics/2017/9/22/16351494/john-mccain-graham-cassidy-obamacare-repeal">looked dead</a> in the water, with at least four likely “no” votes:</p>
<ul>
<li id="w1vh7T">Sen. John McCain (R-AZ) said he would oppose the bill and called for a return to regular order and bipartisanship.</li>
<li id="9ufvV8">Sen. Rand Paul (R-KY) has repeatedly said he opposed the bill because it kept much of Obamacare’s funding through the block grants.</li>
<li id="heqQpl">Sen. Susan Collins (R-ME) said she couldn’t see herself voting for the bill, given the rollback of protections for preexisting conditions and the Medicaid cuts.</li>
<li id="HfpJTp">Sen. Ted Cruz (R-TX) said he opposed the initial bill, likely because it didn’t go far enough to roll back Obamacare’s insurance rules.</li>
</ul>
<p id="oRguKQ">Sen. Lisa Murkowski (R-AK) hadn’t taken a definitive position on the bill, saying she wanted to review how it would affect Alaska’s funding. But she <a href="https://www.vox.com/policy-and-politics/2017/9/21/16347012/graham-cassidy-murkowski-standards-health-reform">opposed</a> every repeal plan so far, and outside estimates, including those from the Alaska government, have projected significant funding cuts for the state.</p>
<p id="atIzUm">The revised Graham-Cassidy likely starts with two Republican “no” votes: McCain’s concerns about process have not been addressed, and Collins has made protections for preexisting conditions and Medicaid cuts a line in the sand for her. That means it can’t afford to lose any other Republican senators.</p>
<p id="foLBzK">The bill includes blatant funding boosts for some of the holdouts. Alaska is <a href="https://www.vox.com/policy-and-politics/2017/9/24/16359332/graham-cassidy-revised-billions-funding-alaska">the target</a> of several provisions:</p>
<ul>
<li id="fUO8td">$500 million for states that have set up an Obamacare waiver program — a provision likely directed at Alaska, which set up a reinsurance program through the law’s waiver program.</li>
<li id="OyHjaS">Additional federal Medicaid funding made available to certain high-poverty states, which also appears directed to Alaska.</li>
<li id="tUVgHB">One-fourth of an $11 billion contingency fund, available in 2020 and 2021, is reserved for “low-density” states like Alaska.</li>
</ul>
<p id="aP54Rm">Nevertheless, internal Senate Republican estimates project Alaska would still see a $100 million federal funding cut by 2026 under the block grant — though the estimates argue that because the state would save money on its share of Medicaid expansion, the state would see a net 3 percent bump in funding. (It should also be noted that the GOP’s internal estimates have been rosier than those from outside groups.)</p>
<p id="NwSScN">Murkowski has also opposed scaling back the protections for preexisting conditions and ending Obamacare’s Medicaid expansion, both of which Graham-Cassidy would still do.</p>
<p id="ux6ea6">On the conservative side, Cruz might be appeased by the further rollback of Obamacare’s insurance rules, but Paul does not appear to be. He has been fixated on Graham-Cassidy’s block grants, arguing that they amount to keeping 90 percent of Obamacare.</p>
<p id="Ac6V2N">The Kentucky senator indicated to <a href="https://www.washingtonpost.com/politics/sen-rand-paul-lays-out-demands-on-health-care-as-talks-continue/2017/09/24/b66ed474-a14d-11e7-ade1-76d061d56efa_story.html?utm_term=.cccc6121ac88">the Washington Post</a> over the weekend that he could support the bill if the block grants were cut in half, but the latest version of the bill does not take such drastic steps.</p>
<p id="n1H5fy">Paul, accordingly, still opposes the bill.</p>
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<blockquote class="twitter-tweet">
<p lang="en" dir="ltr">Rand Paul is still a "no" on the latest version of Graham-Cassidy, aide tells <a href="https://twitter.com/mj_lee">@mj_lee</a></p>— Phil Mattingly (@Phil_Mattingly) <a href="https://twitter.com/Phil_Mattingly/status/912318582960398336">September 25, 2017</a>
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<p id="Uf2Ffa">So Graham and Cassidy are still tinkering, searching for some sweet spot that gets them to 50 votes by the end of September. But despite further gutting of Obamacare’s insurance rules and some direct buyoffs for key swing votes, they still don’t appear to have a majority.</p>
<p id="6oVkYr">They have five days to keep working at it.</p>
<hr class="p-entry-hr" id="6ffxBI">
<h3 id="Pzq5Bu">Join the conversation</h3>
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https://www.vox.com/policy-and-politics/2017/9/25/16360550/graham-cassidy-revised-explainedDylan Scott