It has been dizzying trying to keep up with the latest GOP effort to repeal and replace parts of the Affordable Care Act, the so-called Graham-Cassidy bill (named after its two key sponsors, Sen. Lindsey Graham of South Carolina and Sen. Bill Cassidy of Louisiana).
As of Wednesday morning, the bill appeared to be dead, but here, for posterity's sake, are three things to remember about Graham-Cassidy.
1. The no-politics, no-spin answer on how the bill handles pre-existing conditions.
What does this bill really do to the ACA requirement that plans cover pre-existing conditions? The answer is, on its face, nothing — the protections are not repealed.
However, in repealing Medicaid expansion and turning Medicaid into a block grant program for which states must apply, the bill allows states to request waivers from certain ACA requirements. Those waivers could include the ability to vary rates based on age or health status and to deviate from the federal list of benefits that must be included in insurance plans — a backhanded way of chipping away at some ACA protections.
These waivers only apply to plans that use those block grant funds. The ACA protections would remain for traditional Medicaid and group plan populations.
This is a central piece of the Graham-Cassidy philosophy: That control over healthcare should be ceded back to the states, and states should be allowed to resume their role as laboratories for experimentation and innovation.
As a backstop — and a way to address the “Jimmy Kimmel test” — the bill also requires that states seeking waivers explain how they will maintain access to affordable coverage for patients with pre-existing conditions. But within those confines, states could get a lot of flexibility in how they provide and oversee insurance coverage to constituents.
2. Bipartisanship is done, at least for now.
Those proposed changes have led to a hue and cry that is decidedly partisan by nature. But wasn’t Congress supposed to be taking a different approach — to healthcare reform writ large, and to the ongoing drama over cost-sharing subsidies?
For a while, it was. Many applauded Senators Lamar Alexander of Tennessee and Patty Murray of Washington over the past month for their bipartisan efforts. As the Chairman and Ranking Member, respectively, of the Senate Health, Education, Labor, and Pensions Committee, they rolled up their sleeves following the last failed ACA repeal attempt and started to look for joint solutions for a healthcare system that everyone can admit leaves room for improvement.
However, as repeal talks heated back up, Alexander released a statement formally ending the collaboration. "We have worked hard and in good faith, but have not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders' hands that could be enacted," Alexander said.
3. Democrats still have some tricks up their sleeves.
With the White House and majorities in both chambers firmly in the hands of the GOP, it might seem like a little more intra-party unity will make a repeal of the ACA inevitable. But don’t count out the Senate Democrats just yet.
All year, the GOP has relied on self-created urgency to try to pass ACA repeal. This time, there is actual urgency. Republicans are aiming to use the 2017 budget reconciliation process to pass Graham-Cassidy with a simple majority, as they only hold 52 seats in the Senate. But the 2017 fiscal year ends September 30, and the Senate Parliamentarian has ruled that reconciliation must happen during the fiscal year to which it applies (finally — common sense from Washington!)
This means the clock is actually ticking: Republicans need to pass something by the end of the month. Democrats are mobilizing to pressure a few Republican Senators who still may vote “no,” but they are also gathering their delay tactics. If they can bring enough amendments to the floor during a process known as “vote-a-rama,” they can potentially delay the vote on the Graham-Cassidy bill until after September 30, tanking repeal efforts on pure technicalities.
Drowned in the details yet? Stay strong – we’ve got another week ahead of crazy days for the ACA.
Stephanie Zaremba is director of government affairs at athenahealth.