ACA and Medicaid under attack. Again.

This week we’re on red alert in response to reports that Republican leadership is gearing up for a vote to repeal the Affordable Care Act (ACA) and gut Medicaid the week of September 25, with a sham hearing possible before then. Now is the time to call, write, and rally to urge the Senate to reject this new threat and support a bipartisan package instead.

The bill, known as Graham-Cassidy-Heller-Johnson for its sponsors Senators Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), and Ron Johnson (R-WI), is being sold as a “compromise” and “non-partisan” solution—even though no Democrats support it. But not only is Graham-Cassidy not a compromise, it is the most radical proposal yet. And like the proposals that preceded it, the bill goes far beyond Republicans’ campaign pledge to repeal the ACA; it also attacks long-standing traditional Medicaid.

Republicans only have two weeks to ram through repeal with just 50 senators and Vice President Mike Pence because on September 30, when the current fiscal year ends, the special process known as “reconciliation” will turn back into a pumpkin and Republicans will once again need 60 votes to overcome a filibuster on any health care package.

But first, a bit of background:

Medicaid and the ACA

Traditional Medicaid, enacted in 1965, is sometimes described as “low-income and...” because to qualify, an individual must fit into a second category; for example, he or she must be low-income and pregnant, low-income and disabled, low-income and elderly, and so on. Prior to the ACA, simply living below the poverty line wasn’t enough to qualify for coverage in most states, so millions of low- and middle-income adults had no access to health insurance. But even with those limitations, traditional Medicaid covers 75 million people across every state and half of all births nationwide. Furthermore, millions of middle-income families also rely on Medicaid to help them afford long-term care (such as nursing home care or home health care aides) for elderly family members.

The ACA, enacted in 2010, increased coverage in two ways. First, for those living below 138% of the federal poverty level, the ACA expanded Medicaid, giving low-income adults who didn’t otherwise qualify for Medicaid the same guarantee of high quality coverage. The ACA as written made the Medicaid expansion mandatory for all states, but in 2012 the Supreme Court made it optional. Nineteen states have refused to expand, leaving millions of their residents in a coverage gap. The intra-party battle in Congress this year has been heavily influenced by the dispute between the Republican governors who responsibly covered their constituents by expanding Medicaid and those who didn’t and now want to be rewarded by the party for fighting “Obamacare” at the expense of their constituents and state budgets.

The second way the ACA expanded coverage was by helping low- and moderate-income households living over the federal poverty line buy private health insurance in the individual market. The ACA subsidizes both premium expenses and out-of-pocket costs like co-pays and deductibles.

Because the ACA was drafted under the assumption that Medicaid expansion would be mandatory, there's no mechanism under the law for extending coverage to those living below the poverty line in states like Texas and Florida that have chosen not to expand Medicaid for partisan reasons. The technical policy term for those stuck in the coverage gap: shit outta luck.

Under current law, everyone who is eligible for Medicaid or for financial help purchasing private coverage is entitled to it. That coverage guarantee means that the programs are flexible enough to respond to economic downturns, natural disasters, rising medical costs, and an aging population.

In contrast, Graham-Cassidy would end these guarantees for both Medicaid and the ACA, gutting the former and ending the latter altogether.

Graham-Cassidy Guts Traditional Medicaid

Graham-Cassidy would replace traditional Medicaid’s 50-year federal-state partnership with a cap-and-slash system designed to cover less and less each year. Under current law, Medicaid automatically adjusts when public health crises like those resulting from Hurricanes Harvey and Irma suddenly drive up per-person costs. But under Graham-Cassidy, once the federal per-person spending cap has been reached, federal funding cuts off. And natural disasters aren’t the only variables sure to raise costs. The Center on Budget and Policy Priorities (CBPP) warns that under a per capita cap, “federal funding [in traditional Medicaid] for seniors, people with disabilities, and families with children would no longer automatically increase to account for higher costs such as prescription drug price spikes or rising costs resulting from an aging population. States would be responsible for 100 percent of all costs above the cap.”

So how does Graham-Cassidy expect states to cope with these huge cuts? By dropping coverage (like prescription drugs) and dropping people (like pregnant women) that they are currently required to cover.

Graham-Cassidy Repeals the ACA and Replaces It with … Nothing

Starting in 2020, Graham-Cassidy completely eliminates the ACA’s Medicaid expansion and subsidies for purchasing private insurance. As Cassidy himself tweeted, Graham-Cassidy “repeals entire architecture of Obamacare.”

In its place, the bill calculates how much money the federal government would have spent on ACA programs, cuts that by over one-third[1], and then redistributes the much smaller pot as block grants to the states with few strings attached. While the ACA includes consumer protections that prevent insurance companies from selling worthless “junk” insurance, rescinding coverage the moment someone gets sick, or discriminating against people with pre-existing conditions, Graham-Cassidy gives states free rein to reinstate all of the worst insurance practices of the bad old days. That means insurance companies could once again charge non-smoking women more than smoking men, treat rape and domestic violence as pre-existing conditions, and reinstate annual and lifetime caps on coverage.

And if that’s not enough, there’s no requirement that states actually spend the money on providing coverage to low- and middle-income families. States would be free to spend the money on any purpose tangentially related to health care, and could design programs that discriminate against women, people of color, immigrants, LGBTQ people, and other marginalized communities.

In the short term, states that have thus far refused to expand Medicaid—leaving millions of their residents without care—will get an increase in their ACA dollars by taking money away from the states that did a good job covering their residents. While the bill’s formula for distributing funds is complicated, conservative Senator Rand Paul (R-KY)'s cynicism is well-founded when he tweets: “#GrahamCassidy … redistributes money from dem states to republican states.” And that's the point.

Under Graham-Cassidy, the amount of money that the federal government would have spent on ACA programs (i.e. subsidies and Medicaid expansion) is cut by over 1/3 by 2026. The new, much smaller pot is redistributed, taking money away from states that covered their residents and bailing out states that didn't.

Sarah Kliff drives home just how screwed up this is:

Graham-Cassidy introduces an entirely novel funding mechanism for distributing funding: moving money from states that have worked aggressively to expand coverage to those that have made little effort at all. It creates a funding formula that is meant to give states 'more equal' health care funding, tethered to the size of their population.

Perversely, this punishes the states that have expanded coverage the most, either by expanding Medicaid or by getting a lot of people signed up for the marketplace (and thus have higher marketplace subsidies flowing into their state). ...

Look, for example, at what happens in Florida, a state that hasn’t expanded Medicaid but has worked diligently to get its residents enrolled in marketplace coverage. Florida has signed up more of its Obamacare-eligible residents for coverage than any other state. It has the biggest marketplace in the country, and its residents received $5.8 billion in Obamacare tax credits in 2016.

What reward does Florida get in Graham-Cassidy for expanding coverage so dramatically? A $2.6 billion budget cut. And again, this happens specifically because Florida has signed up so many people for Obamacare coverage and thus its residents receive a generous amount of health law tax credits. [emphasis mine]

Of course, as Senator Chris Murphy tweets, perhaps even thinking of this as a transfer between states isn't quite right.

It's not Florida that's getting cut, it's individual Floridians who will lose their health insurance and have to forgo life-saving health care to bail out Texas. Meanwhile, individual Texans who are covered through the ACA will almost certainly lose their insurance even as Texas state politicians get a big old slush fund to play with for a few years.

And that doesn't take into account that every state is getting cut by the per capita cap on traditional Medicaid. Once all of the cuts are factored in, analysis by CBPP finds that all but 8 states will lose millions to billions of dollars under Graham-Cassidy in the years between 2020 and 2026.

And finally, no state will benefit for long. That’s because after 2026 under Graham-Cassidy, traditional Medicaid will be reduced by over one-third while the ACA-turned-block grant funding will disappear altogether to be replaced with… nothing. That’s right, starting in 2027, the bill eliminates every last dollar that the federal government would spend on ACA programs.

Under Graham-Cassidy, the amount of money that the federal government would have spent on ACA programs disappears completely starting in 2027, while traditional Medicaid (not pictured) will limp along, covering less and less each year. How many states are going to build whole new coverage systems from scratch when the funding only lasts 7 years?

And we haven't even gotten into all of the other nasty, mean-spirited, and anti-woman things this bill will do, like attacking the ability of women and men to use Medicaid or other forms of government health insurance at Planned Parenthood for services like cancer screenings, STD treatments, family planning services like birth control, and more.

What’s Next?

Senator John McCain (R-AZ), who dramatically voted against an ACA repeal in July out of concern that the bills hadn’t gone through “regular order”—including a bipartisan process of committee consideration—has said that he supports the bill (bill sponsor Graham is his best friend) but has hedged about whether he could support it in absence of a committee process. In response, bill co-sponsor Johnson told the press, “I’m chairman of Homeland Security. If either the Finance Committee or HELP committees [with jurisdiction] won’t hold a hearing, I’ll [set up] one this afternoon,” simply to check that box.

Under Senate rules, Graham-Cassidy will need a budget “score” from the Congressional Budget Office (CBO) and a “Byrd bath” from the Senate parliamentarian, the process of determining whether individual provisions qualify under the “Byrd rule,” which limits what can be included in a reconciliation package. Republican leaders are pushing for a partial CBO score by next week, one that shows the fiscal impact but not the number of people harmed by cuts to their care.

Should Republicans secure 50 votes on Graham-Cassidy or any other Trumpcare proposal, they will be able to pick up from where they left off in July, with all debate time expired and only the rapid-fire amendment process known as vote-a-rama left. In other words, some of the most consequential legislation in our nation’s history, affecting one-fifth of our economy, could get a vote after only 5 minutes of debate on the Senate floor.

I updated my chart from January to show where we are now.

If we can prevent the Senate from passing repeal legislation before September 30, we will have blocked their ability to pass Republican-only health care legislation for the foreseeable future. But if the Senate passes Graham-Cassidy, the House faces no similar time limit on their ability to pass the bill. They could—and likely would—move to immediately take up the Senate bill and pass it without changes, sending it to Donald Trump for signature. But they could also use the remaining 15 months of this Congress to pressure blue state Republicans to vote for the bill and stymieing hope for a bipartisan package.

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[1] According to CBPP, “The block grant would equal $140 billion in 2020, which is $26 billion, or 16 percent, below projected federal spending for the Medicaid expansion and marketplace subsidies under current law. The block grant would increase annually by roughly 2 percent, to $158 billion in 2026. That wouldn’t even keep pace with general inflation, which the Congressional Budget Office (CBO) projects to equal 2.4 percent annually over that period, let alone with expected growth in per-beneficiary health care costs and enrollment. Thus, by 2026, block grant funding under the plan would be $83 billion, or 34 percent, below currently projected federal spending on the ACA’s major coverage expansions.”