Revised Version of Cassidy-Graham Proposal Is More of the Same
With a vote on the
The latest version of the bill makes changes to the formula for allocating block grant funding among the states, thereby increasing allotments for some states at the expense of others. It also adds new funding provisions that benefit specific states. But the bill's core features remain unchanged: it still eliminates the ACA's Medicaid expansion and marketplace subsidies and replaces them with an inadequate block grant; still ends block grant funding after 2026, creating a massive federal funding cliff that would result in huge coverage losses; still imposes a Medicaid per capita cap that results in large and growing cuts to Medicaid funding for seniors, people with disabilities, and families with children; still eliminates or weakens protections for people with pre-existing conditions; and still imposes a highly unrealistic implementation timeline that would likely leave many or most states' insurance markets and coverage programs in chaos.
What Hasn't Changed
The key features of the Cassidy-Graham bill remain unchanged:
Elimination of the ACA Medicaid expansion and marketplace subsidies that help people purchase coverage. The plan would still repeal the Medicaid expansion, which has extended coverage to 11 million low-income adults, as well as the ACA's marketplace subsidies, which help almost 9 million people afford coverage. Just as in the previous draft, these programs would end after 2019, and would be replaced with a block grant that provides less federal funding -- in fact, the same total national funding as the previous version -- and that leaves states on the hook for any and all unexpected costs from recessions, natural disasters, public health emergencies, or prescription drug price spikes.
Massive coverage losses and market collapse after 2026. Just as in previous versions, the Cassidy-Graham proposal's block grant funding ends altogether after 2026. As a result, starting in 2027, the bill would be equivalent to the repeal-without-replace bill that the
Deep and growing cuts to Medicaid funding for seniors, people with disabilities, and families with children. The revised plan includes the same per capita cap on Medicaid funding outside of the ACA Medicaid expansion,[4] which would cut traditional Medicaid by more than
Elimination or weakening of protections for people with pre-existing conditions. As in prior versions of the bill, the new draft would allow states to eliminate or roll back the ACA's core consumer protections, including its prohibition on charging higher premiums based on pre-existing conditions and its requirements that plans cover essential health benefits such as maternity coverage, and substance use and mental health treatment; offer preventive services without cost sharing; and cap consumers' total annual out-of-pocket costs. In fact, if anything, the new draft is more explicit that states are free to establish market rules that conflict with or eliminate these protections. In order to do so, states would merely have to include in their block grant funding application "a description of how the state shall maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions." (The revised draft, like the earlier version, offers no definition of "adequate and affordable," nor would states have to prove that they have actually maintained coverage for people with pre-existing conditions to continue to receive their block grant funding.)
As the
A deeply unrealistic timeline that would create chaos nationwide. The revised version of Cassidy-Graham would still eliminate marketplace subsidies and Medicaid expansion on
The bipartisan
The Graham-Cassidy legislation would require states to operationalize the block grant component by
Similarly, a bipartisan group of 36 current and former insurance commissioners said in a letter:[8]
All 50 states and the
What Has Changed
While leaving the plan's structural features and its aggregate cuts to federal funding for coverage essentially unchanged, the new version does make changes that have the effect of transferring funding among the states.
Block grant formula. Where the prior version of the plan drastically redistributed resources across states beginning in 2021, the new version phases in its redistribution more slowly -- resulting in somewhat smaller and more gradual funding losses for Medicaid expansion states and states with higher-than-average marketplace subsidy enrollment. But as noted above, there's no change in the total block grant funding levels -- meaning that any gains for some states would come at the expense of others.
Targeted benefits for specific states. Several new provisions in the bill seem to be intended to benefit
A note on new Cassidy-Graham numbers: Senators Cassidy and Graham have also released a new set of numbers to accompany the new bill draft.[9] The Senators released widely debunked numbers[10] with earlier drafts of the bill that appeared to show states like
For expansion states, the Cassidy-Graham estimates add in a "state savings" column which is actually an additional health coverage funding cut. Effectively, the estimates assume that states will cut their own spending on coverage, on top of the loss of the federal funding.
The estimates end after 2026 -- ignoring the huge funding cliff under the bill in 2027.
Footnotes:
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8] "Letter to Senate Majority Leader McConnell, Senate Minority Leader Schumer, House Speaker Ryan, and House Democratic Leader Pelosi,"
[9] "Illustrative State-by-State Impact of Graham-Cassidy-Heller-Johnson (GCHJ) Market-Based Health Care Grant Program (Section 106), Calendar Years 2020-2026," https://www.cassidy.senate.gov/imo/media/doc/GCHJ%20State-by-State%20Impact%20(002).pdf.
[10]
[11] Carpenter and Sloan;
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