ACA repeal in 11 days? 10 things to know Tuesday about the Graham-Cassidy bill

The ACA repeal bill proposed by Sen. Lindsey Graham, R-S.C., and Sen. Bill Cassidy, R-La., has gained momentum in recent days as Republicans whip votes ahead of the September 30 budget reconciliation deadline.

As of Tuesday morning, here are 10 things you need to know about the Graham-Cassidy bill.

1. The Congressional Budget Office has said it could take several weeks before it can provide a point estimate for the bill's impact on the budget deficit, insurance coverage or premium costs. The CBO is aiming to release a bare-bones analysis by early next week. The Senate has also scheduled two hearings on the bill for Monday and Tuesday.  

2. The budget reconciliation rule, which allows the Senate to pass healthcare bills with a simple majority vote, is set to expire September 30. This deadline is key as it allows Senate Republicans to pass legislation on a party-line vote, meaning 50 votes are needed for passage.

3. Senate Majority Leader Mitch McConnell, R-Ky., has said that he will bring the bill to the floor for a vote and support it if Mr. Graham and Mr. Cassidy can demonstrate they have the 50 votes necessary to pass it.

4. The big question now is whether the Republican party can drum up 50 votes in 11 days. One vote is out: Sen. Rand Paul, R-Ky., said he will not support the bill because it maintains ACA taxes and does not do enough to repeal the ACA, according to MSNBC.

5. Arizona Gov. Doug Ducey (R) has endorsed the bill, according to CNBC, which is important given the influential role of Sen. John McCain, R-Ariz. He cast the deciding vote that killed Republican ACA repeal efforts in July when he sided with Democrats and voted against the "skinny" repeal bill, along with Sen. Susan Collins, R-Maine, and Sen. Lisa Murkowski, R-Alaska. It is unclear how Mr. Ducey's endorsement will affect Mr. McCain's support of the proposal. He had previously said he would vote for Graham-Cassidy if Mr. Ducey supported it, but has since said he is not yet supportive of the bill. 

6. The fact that a vote on the legislation may occur before the CBO can release its full score of the bill may hinder support from Sens. Collins, Murkowski and McCain.

7. Rebekah Gee, MD, secretary of health in Mr. Cassidy's home state of Louisiana, has come out against the proposal, writing that "in its current form, the harm to Louisiana from this legislation far outweighs any benefit," making particular note of cuts to Medicaid expansion.

8. President Donald Trump has said he supports the bill and will sign it into law if it crosses his desk.

9. Analysts say the Graham-Cassidy measure would more drastically remold the ACA by giving states virtually unlimited control over federal dollars that are currently spent on marketplace subsidies and Medicaid expansion. The bill looks to roll back Medicaid expansion and eliminate federal premium subsidies and instead distribute the money spent on these programs to states in the form of block grants. A per-capita Medicaid cap would be imposed under the bill, setting a limit on the amount of Medicaid dollars each enrollee is eligible to receive. Because block grant funding is also capped, states would not be able to give premium subsidies to those who become eligible for such subsidies if their economic conditions change.

10. Under Graham-Cassidy, block grant funding will grow slower than the rate of rising healthcare costs. Though Sens. Cassidy and Graham tout the bill's emphasis on state flexibility, the rate of block grant funding growth would leave states with 34 percent less funding for healthcare by 2026 than they would have had under the ACA, according to The Washington Post. This lack of growth is especially pronounced for states that expanded Medicaid, with states like California and New York facing a 50 percent decrease in healthcare funding by 2026. The bill also allows states to waive certain ACA essential health benefits, no longer providing protections for those with preexisting conditions.

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