Four GOP se­na­tors

The Washington Post - - FRONT PAGE - BY DAVID WEIGEL AND AMY GOLD­STEIN david.weigel@wash­post.com amy.gold­stein@wash­post.com

rolled out a plan to de­volve the Af­ford­able Care Act into state-bystate block grants.

With just 17 days left for Repub­li­cans to re­peal the Af­ford­able Care Act on a party-line vote, a quar­tet of GOP se­na­tors on Wed­nes­day rolled out a plan to de­volve fed­eral health-care spend­ing into state-by-state block grants — leg­is­la­tion that Sen. Lind­sey O. Gra­ham (S.C.) de­scribed as con­ser­va­tives’ last shot at re­form.

“It should have been our first bill to re­peal and re­place Oba­macare, but it is now our last,” Gra­ham said at a morn­ing news con­fer­ence. “To those in the Repub­li­can Party who feel like we have not fought as hard as we could, you’re right.”

The Gra­ham-Cas­sidy-Heller-John­son bill, named for cospon­sors Gra­ham, Bill Cas­sidy (La.), Dean Heller (Nev.) and Ron John­son ( Wis.), would turn the bil­lions of dol­lars spent on the ACA’s Med­i­caid ex­pan­sion, tax cred­its and sub­si­dies into grants man­aged by each state.

The bill rep­re­sents a fun­da­men­tally dif­fer­ent ap­proach to over­turn­ing much of the sprawl­ing 2010 health-care law then other mea­sures Se­nate Repub­li­cans have at­tempted — and failed to achieve — this year.

It would leave in place most of the fi­nan­cial props that sup­port the ACA, elim­i­nat­ing only a tax on med­i­cal de­vices. At the same time, it does not at­tempt to re­place the cur­rent law’s poli­cies with more con­ser­va­tive fed­eral ap­proaches, in­stead al­low­ing each state to de­fine its own rules for health plans that may be sold to res­i­dents and the help con­sumers should re­ceive to af­ford that in­sur­ance.

“It’s a mas­sive de­vo­lu­tion of fed­eral money and re­spon­si­bil­ity to states, on a scale I don’t think we’ve ever seen,” said Larry Le­vitt, se­nior vice pres­i­dent of the Kaiser Fam­ily Foun­da­tion. “Over time, it’s less fed­eral money than is be­ing spent now on health care, but it’s still a huge pot of money avail­able to states with very few strings at­tached.”

While main­tain­ing the ACA’s taxes, the pro­posal would re­peal many of the law’s features dis­liked by Repub­li­cans, in­clud­ing the re­quire­ments that most Amer­i­cans carry in­sur­ance and that large em­ploy­ers of­fer health cov­er­age. It would al­low states to waive most of the law’s in­sur­ance reg­u­la­tion but con­tinue its ban on in­sur­ers re­fus­ing to cover peo­ple with pre­ex­ist­ing med­i­cal con­di­tions.

The plan would end the pre­mium tax cred­its that the ACA pro­vides to more than 80 per­cent of the ap­prox­i­mately 10 mil­lion Amer­i­cans who have health plans through mar­ket­places cre­ated un­der the law. And it would elim­i­nate cost-shar­ing dis­counts the law pro­vides lower-in­come con­sumers with mar­ket­place plans to help them af­ford de­ductibles and other other-of-pocket ex­penses. States could de­cide whether to cre­ate new forms of fi­nan­cial help for buy­ing in­sur­ance.

The bill’s main com­po­nents would start in 2020, and the fund­ing it en­vi­sions would last un­til 2026, lim­ited by the 10-year bud­get win­dow.

The amount of money each state would re­ceive as a block grant would hinge on how many res­i­dents fall roughly within the in­come groups el­i­gi­ble for Med­i­caid un­der an ex­pan­sion of the pro­gram that about three-fifths of the states have adopted un­der the ACA — peo­ple with in­comes of up to 138 per­cent of the fed­eral poverty level.

But the block grant could be spent on a va­ri­ety of health-care pur­poses, not just to help low­er­in­come peo­ple gain cov­er­age. States would de­cide whether to pre­serve, or be­gin, their Med­i­caid ex­pan­sion.

What’s un­cer­tain is how the bill could beat the buzzer — the end of the bud­get rec­on­cil­i­a­tion re­con­struc­tions that Repub­li­cans hoped they could use to re­peal most of the ACA with just 50 votes, plus the tiebreak­ing sup­port of Vice Pres­i­dent Pence.

The GOP’s anti-Oba­macare push, which has been on hold since three Repub­li­can se­na­tors blocked a “skinny re­peal” bill on July 28, ap­peared to end in Au­gust. Over the long sum­mer re­cess, both party lead­ers and out­side groups be­gan talk­ing and buy­ing TV ads to pro­mote tax cuts, the pres­i­dent’s next do­mes­tic agenda item.

“What has been pro­posed isn’t ac­tu­ally re­peal and re­place,” said Dan Holler, the com­mu­ni­ca­tions di­rec­tor at Her­itage Ac­tion, an­other of the ma­jor con­ser­va­tive pro- re­peal groups. “I’m not con­vinced that the so­lu­tion here is to un­veil an­other sweep­ing bill ahead of a tight dead­line. That hasn’t worked for any­one so far.”

On Sept. 1, the Se­nate par­lia­men­tar­ian ruled that the end of the fis­cal year on Sept. 30 would mean the end of the party’s abil­ity to pass a bill with a sim­ple ma­jor­ity. Gra­ham and Cas­sidy, the main spon­sors of the lat­est plan, kicked into over­drive, sub­mit­ting text to the Con­gres­sional Bud­get Of­fice last week and ar­gu­ing that the bulk of their idea had al­ready been vet­ted when Cas­sidy and Sen. Su­san Collins (R-Maine) floated a sep­a­rate pro­posal.

“You play with the hand that’s dealt,” Cas­sidy said.

The se­na­tors say they could fit hear­ings into the tight sched­ule, and they ac­knowl­edge those ses­sions would mat­ter be­cause of the rea­sons that “skinny re­peal” died. Sen. John McCain (R-Ariz.), who cast the de­cid­ing vote against it, ar­gued that both par­ties needed to re­turn to reg­u­lar or­der. The new bill’s back­ers said they could wran­gle the sup­port they needed, the score they needed and move through the com­mit­tee process be­fore the dead­line.

John­son and Gra­ham also sug­gested that con­ser­va­tive gov­er­nors could build mo­men­tum for the bill, if the White House worked on them to en­dorse it and ex­plained how their states would ben­e­fit from block grants.

Yet even be­fore the col­lapse of the first re­peal push, mod­er­ate Repub­li­can gov­er­nors such as Ohio’s John Ka­sich and Ne­vada’s Brian San­doval were urg­ing Congress to move on and pass com­pro­mise leg­is­la­tion that would fully fund the ACA’s tax sub­si­dies.

Asked whether his gover­nor backed the lat­est plan, Heller said that it was a “work in progress.”

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