What would the Graham-Cassidy health care bill do?

WASHINGTON—Senate Republicans are rushing to vote by the end of next week on a new bill to roll back the Affordable Care Act.

The latest bill—authored by Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La.—has been put together so quickly that the independent Congressional Budget Office said it will not have time to fully evaluate its impact before a vote.

Here is a rundown of the main parts of the bill and its impact:

Q: How different is this from the previous Republican repeal bills?

A: The Graham-Cassidy proposal shares some features of earlier repeal legislation approved in the House and debated in the Senate, including scrapping the requirement that Americans have health coverage and placing new restrictions on federal funding for Planned Parenthood.

But the new repeal bill is substantially more sweeping and goes far beyond just repealing the 2010 health care law, often called Obamacare.

The Graham-Cassidy proposal would completely restructure how the federal government provides health care assistance to some 80 million Americans and create a new system for distributing hundreds of billions of dollars of government aid.

That would represent the largest change in the way health care is financed in the United States in more than half a century.

Q: How would that happen?

A: The bill would first do away with the government’s two main tools for providing health insurance coverage to low- and moderate-income Americans.

Graham-Cassidy would eliminate insurance subsidies provided through the Affordable Care Act to about 8 million consumers who earn too much to qualify for the Medicaid program.

And it would eliminate the half-century-old system of federal Medicaid funding, which currently provides money to states to cover poor children, mothers, senior citizens and the disabled.

State Medicaid programs today insure more than 70 million Americans. That includes millions who have gained coverage since 2014 through the Affordable Care Act, which provided additional federal funds to states to make Medicaid available to poor, working–age adults, a population traditionally not eligible for coverage.

In place of the current law’s insurance subsidies and the Medicaid funding, Graham-Cassidy would provide states with a set amount of federal money that they could use as they choose to provide health care assistance to their residents. This federal funding would then be capped.

That would effectively end the federal government’s promise to guarantee health insurance for all low-income Americans.

Q: What is the benefit of this arrangement?

A: The bill’s supporters say giving states more flexibility to decide how they provide health care assistance to their residents will free them to design better, locally-controlled systems.

Graham and Cassidy note that unlike some earlier GOP repeal bills, their proposal keeps most of the tax revenue raised by the 2010 law, allowing the federal government to continue providing hundreds of billions of dollars of assistance.

At the same time, putting a cap on that aid in future years would limit how much health care spending the federal government would have to make.

The Graham-Cassidy bill stops federal health care aid to states in 2026, meaning Congress would have to find new money for aid after that.

Q: What would happen to insurance protections enacted in the Affordable Care Act?

A: The 2010 law imposed revolutionary new national standards on health insurance.

Insurers were prohibited from turning away sick customers or charging them more for coverage, practices that were once common.

Plans could not impose annual or lifetime limits on coverage and had to offer a basic set of benefits, including prescription drugs, maternity care and mental health and substance abuse services. They also could not charge older consumers more than three times as much as younger ones.

Graham-Cassidy wouldn’t do away with the ban on insurers turning away sick customers.

But it would give states new authority to circumvent many other protections, including allowing insurers to once again charge more to people with pre-existing medical conditions.

Q: So would people lose coverage? A: Almost certainly. The nonpartisan Congressional Budget Office has estimated that previous GOP repeal bills that gave states the ability to waive consumer protections would make it harder for sicker people to get health coverage.

That would, in turn, drive up the number of uninsured.

Independent analyses of proposals to cap federal funding to states also estimate that would lead to an erosion in coverage as the cost of providing health care assistance over time grows more rapidly than the cap.

Graham-Cassidy would likely have the most impact on coverage in states such as California, New York, Illinois and others that have expanded coverage most aggressively under the current law.

The arcane funding formula in the new GOP proposal would effectively shift money away from these states to more conservative states that have resisted coverage expansions.

That could mean much less assistance for poor residents of California and elsewhere and consequently major coverage losses in those states.

Q: What would happen to people’s premiums?

A: This is hard to know without a more thorough analysis by the Congressional Budget Office.

Previous estimates by the office have projected that reducing regulations might make health plans more affordable to some consumers, but only because health plans could offer less comprehensive benefits and could charge higher deductibles.

Sicker and older consumers would likely see their premiums increase, as could lower-income consumers, who would no longer get federal assistance with their insurance costs.

Q: What do patient groups and people who work in health care say about the bill?

A: Leading patient advocates, hospitals and physicians groups have strongly criticized the proposal, warning it could have devastating effects on patients.

On Monday, a coalition of 16 patient groups condemned the proposal.

“This legislation fails to provide Americans with what they need to maintain their health,” the groups said in a statement, echoing similar criticism leveled last week by the AARP, physician groups and the country’s safety net hospitals.

The patient groups— which include the American Diabetes Association, American Heart Association, American Lung Association, March of Dimes and the National Multiple Sclerosis Society—warned the bill “would roll back important essential health benefit protections and potentially open the door to annual and lifetime caps on coverage, endangering access to critical care for millions of Americans.”

Last week, six leading physician groups, including the American Academy of Family Physicians, the American College of Physicians and the American Academy of Pediatrics, said in a letter to congressional leaders that the new GOP proposal “fails to protect the health care coverage and consumer protections available under current law.”