The Byrd rule, however, restricts what can be considered under budget reconciliation. If a provision of a bill is considered an “extraneous matter” or something “merely incidental” to the federal budget, it can be stripped out of the legislation….
A previous iteration of the Senate GOP’s healthcare bill, the Better Care Reconciliation Act, already showed what may happen with the waivers in the new bill. During the Byrd bath, the waivers in the BCRA that allowed the loosening of EHBs and other regulations were deemed to have nothing to do with the budget and were ordered stripped from the bill.
Health-policy experts say this could indicate that the waivers in the Graham-Cassidy bill will also have to be stripped.” (A)

“The fundamental thing to understand about Senate Republicans’ latest attempt to repeal Obamacare is that the bill under consideration would not just undo the Affordable Care Act—it would also end Medicaid as we know it and our federal government’s half-century commitment to closing the country’s yawning gaps in health coverage. And it would do so without putting in place any credible resources or policies to replace the system it is overturning. If our country enacts this bill, it would be an act of mass suicide…
The Graham-Cassidy bill goes even further than the bill passed by the House. It would bring to a virtually immediate end not only the individual and employer mandates but also the whole edifice of the Medicaid expansion, insurance exchanges, and income-based coverage subsidies set up under the A.C.A. Graham-Cassidy expects all fifty states to then pass, and implement, alternative health systems for tens of millions of people within two years—with drastically less money, in most states, than the current law provides. This is not just impossible. It is delusional.” (B)

What every state stands to gain or lose under Graham-Cassidy, according to CMS.
Highlight and click on http://www.beckershospitalreview.com/hospital-management-administration/what-every-state-stands-to-gain-or-lose-under-graham-cassidy-according-to-cms.html

“The states with populations that would be hurt most by such a scheme aren’t California and New York, but cash-strapped, smaller, mostly-rural states or Rust Belt states that decided to expand Medicaid, often in order to meet extraordinary statewide health crises. These states are not liberal bastions Graham claims are favored by Obamacare; rather these states—Louisiana, Arkansas, Arizona, Kentucky, Ohio, Indiana, Maine, Iowa, Alaska, New Mexico, North Dakota, West Virginia, and Montana—are largely dominated by Republicans, and make up a large swathe of the party’s geographic base.” (C)

“One area where states would get more discretion under the bill involves their obligation to cover Americans with pre-existing conditions. States would be permitted to waive pre-existing condition protection as long as they still provide “adequate and affordable” coverage — but what qualifies as “affordable” is left undefined.
What will be the effects of these changes? Consumers will almost certainly see rising premiums and health care costs because subsidies are being replaced. There may be less coverage provided if states aren’t able to do more with less, as Cassidy and Graham are purporting. But no one really knows the extent of the cost or coverage changes. Supporters of the bill are intentionally vague about what the effects will be, saying that states know better how to allocate money, that they shouldn’t have Obamacare forced upon them, and, essentially, that we’ll see what happens when it happens…
Adequate and affordable” coverage for consumers with pre-existing conditions is a concept that’s so nebulous it’s useless…”(D)

“Since money is fungible and the block grants have few strings attached, states can in effect use the cash to fund projects that have nothing to do with health care. This is how: All states would need to do is identify existing state health care programs that qualify for block grant funding, thereby freeing up the state dollars currently devoted to those program to be used in whatever way the state wishes. If this were a state’s goal, the legislation makes it easy to achieve….” (E)

“Coalitions of health professionals that have spoken publicly against the measure so far include the American Medical Association (“Provisions violate longstanding AMA policy”), the American Psychiatric Association (“This bill harms our most vulnerable patients”), the American Public Health Association (“Graham-Cassidy would devastate the Medicaid program, increase out-of-pocket costs, and weaken or eliminate protections for people living with preexisting conditions”), the National Institute for Reproductive Health (“the Graham-Cassidy bill preys on underserved communities … a clear and present danger”), and Federation of American Hospitals (“It could disrupt access to health care for millions of the more than 70 million Americans”). (F)

“Americans by more than a 20-point margin prefer the existing federal health care law to the latest, imperiled Republican alternative — another challenge to the GOP’s long-held effort to repeal and replace Obamacare.
The public supports Obamacare over the proposed Graham-Cassidy bill by 56-33 percent in a new ABC News/Washington Post poll. Intensity of sentiment also is on the current law’s side: Forty-two percent strongly prefer it, nearly twice as many as strongly prefer the GOP plan.
The result is similar to public views on the previous GOP repeal-and-replace effort, which failed in July. Americans preferred Obamacare to that plan by 50-24 percent, again with a 20-point advantage for the current law in strong sentiment.” (G)

“For months now, proposals to repeal and replace the Affordable Care Act have risen and fallen in the House and the Senate, almost always uniting health care providers and patient advocacy groups in opposition but winning support among conservatives, including Republican policy makers. But the version drafted by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana — and hastily brought into the spotlight last week — went further.
It brought much of the health care world together to stop it, an effort that appears to have succeeded — not for ideological reasons, but for the simple reason that administrators, caregivers, advocates and insurers believed it could not work.” (H)

The president had embraced the legislation in recent days, making telephone calls to wavering senators and dispatching Vice President Mike Pence to Capitol Hill to try to build support for its passage. Mr. McCain’s announcement that he would not vote for it came just hours after the president had warned in a Friday post on Twitter that any Republican who opposed the measure “will forever (future political campaigns) be known as ‘the Republican who saved ObamaCare.’ ”
On Saturday, Mr. Trump appeared to be nurturing hopes that the legislative effort could be kept alive. He expressed hope that Mr. Paul would rethink his opposition to the Graham-Cassidy measure, without explaining why the Kentucky senator, who had complained that the bill left the Affordable Care Act’s essential structure intact, might do so.” (I)

(A) The healthcare bill could blow up in the GOP’s face because of an obscure Senate rule, by Bob Bryan, http://www.businessinsider.com/graham-cassidy-health-care-bill-byrd-rule-2017-9
(B) If the U.S. Adopts the G.O.P.’s Health-Care Bill, It Would Be an Act of Mass Suicide, by Atul Gawande, https://www.newyorker.com/news/news-desk/if-the-us-adopts-the-gops-health-care-bill-it-would-be-an-act-of-mass-suicide
(C) The Real Losers of the Graham-Cassidy Health-Care Bill, by VANN R. NEWKIRK II, https://www.theatlantic.com/politics/archive/2017/09/graham-cassidys-false-redistribution/540438/
(D) John McCain’s no vote won’t necessarily kill Graham-Cassidy health bill, by Jennifer Fitzgerald, https://www.cnbc.com/2017/09/22/graham-cassidy-repeal-bills-huge-unknowns-for-consumers-commentary.html
(E) What the CBO Might Have Said about Graham-Cassidy, by ROBERT VERBRUGGEN, http://www.nationalreview.com/corner/451642/what-cbo-might-have-said-about-graham-cassidy
(F) Doctors: No. Physicians rarely agree on anything as strongly as they do that the Graham-Cassidy health-care bill is harmful, by JAMES HAMBLIN, https://www.theatlantic.com/health/archive/2017/09/do-no-harm/540333/
(G) Public prefers Obamacare to Graham-Cassidy, 56-33% (POLL), by GARY LANGER, http://abcnews.go.com/Politics/public-prefers-obamacare-graham-cassidy-56-33-poll/story?id=50031499
(H) Why the Latest Health Bill Is Teetering: It Might Not Work, by SHERYL GAY STOLBERG, and ROBERT PEAR, https://mobile.nytimes.com/2017/09/23/us/obamacare-repeal-graham-cassidy-mccain-trump.html
(I) Trump Laces Into McCain Over His Opposition to Health Care Bill, by JULIE HIRSCHFELD DAVIS, https://www.nytimes.com/2017/09/23/us/politics/trump-mccain-graham-cassidy-health-care-obamacare.html?mcubz=0

“As I have repeatedly stressed, health care reform legislation ought to be the product of regular order in the Senate. Committees of jurisdiction should mark up legislation with input from all committee members, and send their bill to the floor for debate and amendment. That is the only way we might achieve bipartisan consensus on lasting reform, without which a policy that affects one-fifth of our economy and every single American family will be subject to reversal with every change of administration and congressional majority.
“I would consider supporting legislation similar to that offered by my friends Senators Graham and Cassidy were it the product of extensive hearings, debate and amendment. But that has not been the case. Instead, the specter of September 30th budget reconciliation deadline has hung over this entire process….” (A)

The latest Republican effort to dismantle the Affordable Care Act stood on the brink of failure Friday after Sen. John McCain (R-Ariz.) announced his opposition to the proposal and Sen. Susan Collins (R-Maine) said she was leaning against it.
The intensifying resistance dealt a potentially decisive blow to the renewed attempt to fulfill a seven-year-old GOP promise. McCain joined Sen. Rand Paul (R-Ky.) in formally opposing the plan, leaving party leaders one senator away from defeat.
Friday’s developments forced Senate Majority Leader Mitch McConnell (R-Ky.) and President Trump into a difficult corner. They must now decide whether to continue to pursue a vote that increasingly appears likely to fail, or short-circuit the endeavor and deal with the backlash after another unsuccessful try. (B)

“..Here’s a giveway about how bad the new Senate health care bill is: Bill Cassidy, one of its authors, keeps trying to sell it by telling untruths. “The relatively new phenomenon of just ‘up is down’ lying about your bill’s impacts is jarring,” says Loren Adler of the USC-Brookings-Schaeffer Initiative on Health Policy.
Most egregiously, Cassidy is claiming that the bill would not ultimately deprive sick people of health insurance. That’s false, as NPR calmly explained when Cassidy said otherwise. In fact, the bill — known as Graham-Cassidy — would free states to remove insurance protections for people with pre-existing conditions. Without those protections, insurers could price such people out of the market.
“If you get cancer (or even have a family history of it) or your child is born with a birth defect — among many, many other health issues — you could find yourself unable to buy insurance. Without insurance, you could be denied crucial treatments. In a tangible way, Graham-Cassidy would harm millions of Americans.” (C)

Bernard Tyson, chairman and CEO of the sprawling Kaiser Permanente nonprofit health system: “At Kaiser Permanente, we believe that changes to our nation’s health care laws should increase access to high-quality, affordable care and coverage for as many people as possible. The Graham-Cassidy bill does not meet any of those tests,” .. “The block grant proposal in the bill would erode coverage of needed medical services and pose major issues for state budgets. Repealing the individual mandate without alternative incentives for enrollment will lead to fewer people enrolled and higher premiums,” he said. Doctor and hospital groups like the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) have similarly denounced the legislation.” (D)

“The current language in Cassidy-Graham — which the Senate may vote on next week — complies with conservatives’ litmus test. But activists acknowledge the Senate parliamentarian will probably strip the Hyde language from the measure altogether, meaning that federally subsidized plans could keep covering abortions.
In the last go-round, that’s exactly what conservatives were worried about, too: that the Hyde amendment would be eliminated from the (now defeated) Better Care Reconciliation Act pushed by Senate Republicans under special rules governing the budget process. (That’s the vehicle Republicans are using to try to overturn much of the ACA because it doesn’t require Democratic votes.) Democrats believed that the parliamentarian agreed with them in that the Hyde language had to go, though Republicans said that guidance wasn’t final.” (E)

“…because it was bipartisan, non-extreme and did not afford the Republican Senate a win for the sake of winning and the chance to get back in the good graces of the manifestly unfit and unstable president, Senate Majority Leader Mitch McConnell (R-Ky.) stepped in to nix it.
That is what, according to multiple sources, happened yesterday as Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) cleared the decks on substantive issues. But then Alexander got yanked back. He hinted at the pressure he was under when he told the press he was “not a magician.” Too embarrassed to acknowledge he’d been stomped on by McConnell, he put out a patently disingenuous statement. “Senator Murray and I had hoped to agree early this week on a limited, bipartisan plan to stabilize 2018 premiums in the individual health insurance market that we could take to Senate leaders by the end of the month,” he said. “During the last month, 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.” In fact the only problem was his majority leadership, desperately straining to please the president with a partisan, fly-by-night repeal of Obamacare.” (F)

4 charts that explain what Graham-Cassidy will do, By Chris Cillizza and Sam Petulla, highlight and click on http://www.cnn.com/2017/09/22/politics/cassidy-graham-charts/index.html

‘…Since the bill doesn’t define what “access to adequate and affordable coverage” means, critics say that it is effectively sanctioning a return to the days before the A.C.A., when sick people in many parts of the country found it extremely difficult and costly to get health coverage.
Usually, in these types of disputes, the nonpartisan analysts at the Congressional Budget Office act as the arbiters. When “scoring” a health-care bill such as Graham-Cassidy, they go through each of its major proposals and provide numerical estimates of its likely effects. In this instance, though, the Republicans are exploiting the fact that the C.B.O. hasn’t had time to do a detailed analysis of their bill—it is expected to produce just a truncated report before next week’s vote.” (G)

“If the latest Republican bill to repeal Obamacare passes, 21 million fewer people will have insurance by 2026, according to a new analysis Friday…
The authors of the Brookings study cautioned that the effects of the bill were difficult to predict given the many paths individual states could take, but they looked a variety of scenarios based on how much block grant funding states devoted to coverage and on how many states maintained Obamacare’s protections for patients with pre-existing conditions, which states could weaken under the bill.
At the same time, the report said that its conclusion “likely understates the reductions in insurance coverage,” because it doesn’t consider potential turmoil if states can’t enact a functional health care system by 2020, when they would transition from Obamacare to the new block grants. Experts have also warned that the bill could cause premium spikes and instability as insurers struggle to manage the shift from Obamacare’s exchanges, which are already in fragile shape. Some areas could be left without any insurers on the individual market.” (H)

“Sen. Rand Paul (R-KY) has consistently said he opposes the plan, arguing that it keeps too much of Obamacare for his support. Sen. Susan Collins (R-ME) has not taken a definitive position, but she has raised concerns about how the bill affects people with preexisting conditions and its Medicaid cuts. She is widely considered a “no” vote.
There are a few others, most notably Sen. Lisa Murkowski (R-AK), who haven’t yet said whether they support or oppose the bill, but whose support is thought to be in doubt.
McCain’s opposition comes with the clock ticking down for Senate Republicans to repeal Obamacare. The special privileges they are using to pass a bill with only 51 votes and avoid a Democratic filibuster expire on September 30. After that, they would need to start the process over by passing a budget resolution.
Senate leaders had said that they intended to bring Graham-Cassidy up for a vote next week, though it’s not clear if they would still hold the vote knowing that the bill would fail.” (I)

(A) Sen. John McCain says he cannot support Graham-Cassidy Obamacare repeal bill, by Christina Wilkie, https://www.cnbc.com/2017/09/22/senator-john-mccain-says-he-cannot-support-graham-cassidy-obamacare-repeal-bill.html
(B) Latest GOP effort to dismantle Obamacare on the brink of failure after defections, byy Sean Sullivan, Juliet Eilperin and Kelsey Snell, https://www.washingtonpost.com/powerpost/mccain-says-he-will-vote-no-for-gop-health-care-bill-dealing-major-blow-to-repeal-effort/2017/09/22/077ba8a4-9fc0-11e7-9c8d-cf053ff30921_story.html?deferJs=true&outputType=default-article&utm_term=.6e18092ebe3d
(C) Senator Cassidy, Please Stop Lying about Health Care, by David Leonhardt, https://www.nytimes.com/2017/09/21/opinion/cassidy-graham-health-care.html?_r=0
(D) One of America’s Most Influential Health Care CEOs Just Trashed the Graham Cassidy Obamacare Bill, by Sy Mukherjee, http://fortune.com/2017/09/20/graham-cassidy-obamacare-kaiser-permanente-ceo/
(E) The Health 202: Cassidy-Graham’s abortion ban workaround, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/09/22/the-health-202-cassidy-graham-s-abortion-ban-workaround/59c4196030fb0468cea81a6b/?utm_term=.665c3649c4d0
(F) The McConnell mentality keeps the Senate and Congress dysfunctional, by Jennifer Rubin, https://www.washingtonpost.com/blogs/right-turn/wp/2017/09/20/mcconnell-mentality-keeps-the-senate-and-congress-dysfunctional/?utm_term=.b1808d926aa3
(G) The Graham-Cassidy Health-Care Bill Is a Clear Danger to People with Preëxisting Conditions, by John Cassidy, https://www.newyorker.com/news/john-cassidy/the-graham-cassidy-health-care-bill-is-a-clear-danger-to-people-with-preexisting-conditions
(H) Study: 21 Million More Uninsured Under Graham-Cassidy Health Care Bill, by Benjy Sarlin, https://www.nbcnews.com/politics/congress/study-21-million-more-uninsured-under-graham-cassidy-health-care-n803801
(I) John McCain opposes Graham-Cassidy, in possible death blow to Obamacare repeal, by Dylan, Scott, https://www.vox.com/policy-and-politics/2017/9/22/16351494/john-mccain-graham-cassidy-obamacare-repeal

As HuffPost’s Jonathan Cohn explains, the bill, sponsored by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), leaves most decisions on health insurance to states, as it converts federal money to state grants. States could dismantle key provisions of the Affordable Care Act, such as the requirement that people with preexisting conditions are not denied coverage. Without that requirement, insurers could charge higher insurance premiums based on patients’ medical status.” (A)

“In releasing a revised version of their legislation to repeal and replace the Affordable Care Act (ACA), Senators Bill Cassidy and Lindsey Graham, along with co-sponsors Dean Heller and Ron Johnson, claimed that their bill isn’t a “partisan” approach and doesn’t include “draconian cuts.” In reality, however, the Cassidy-Graham bill would have the same harmful consequences as those prior bills. IT WOULD CAUSE MANY MILLIONS OF PEOPLE TO LOSE COVERAGE, RADICALLY RESTRUCTURE AND DEEPLY CUT MEDICAID, AND INCREASE OUT-OF-POCKET COSTS FOR INDIVIDUAL MARKET CONSUMERS. It would cause many millions of people to lose coverage, radically restructure and deeply cut Medicaid, eliminate or weaken protections for people with pre-existing conditions, and increase out-of-pocket costs for individual market consumers.” (B)

“One GOP senator on Thursday, however, seemed to suggest that the new bill could leave sick Americans worse off. Sen. Jeff Flake of Arizona, a Republican supporter of the Graham-Cassidy bill, said on MSNBC’s “Morning Joe” Thursday that the new plan could allow states to undermine protections for people with preexisting condition. He argued, however, that that wouldn’t end up happening.
“There are provisions in there, I’ve heard it said, that would allow a race to the bottom and states to deny coverage or allow insurance companies to deny coverage [based] on preexisting conditions,” Flake said. “If they’re able to, de jure, de facto, they won’t be able to.”” (C)

“Senators Lindsey Graham and Bill Cassidy, the sponsors of the Graham-Cassidy repeal bill, claim that their bill is different—that it simply shifts health care decisions to the states. This is false. Just like the failed repeal bills that came before it, Graham-Cassidy would result in millions of Americans losing health coverage. And in crucial respects, it’s the most harmful version of repeal yet….
Although Graham and Cassidy claim that this will increase flexibility for states, in reality it will do the opposite. Slashing federal funding will force states to cut eligibility or benefits based on budgetary limits.” (D)

“Graham-Cassidy doesn’t let states waive the part of the Affordable Care Act that says insurers have to cover sick people. But it does allow states to opt out of several other ACA rules that can cause people with pre-existing conditions to pay more for their health care. Those provisions include:
The ban on charging sick people higher premiums than healthy people. The requirement that insurers cover “essential health benefits,” including prescription drugs. People who need expensive drugs might not have access to a plan that covers those drugs, requiring them to pay out of pocket. Services that aren’t “essential” benefits aren’t subject to the ACA’s ban on annual and lifetime limits.
The bill also would also loosen rules about how much insurers can raise their premiums because of a customer’s age. (Older people are more likely to have pre-existing conditions.” (E)

“On Tuesday I wrote that the chances for Senate Republicans’ last stab at Obamacare repeal, Graham-Cassdidy, “may well hang on what offer Republican leaders are willing to make on Alaska’s behalf in the next week” in order to secure Sen. Lisa Murkowski’s pivotal vote. A couple of reports Thursday afternoon show us how that offer may be shaping up. To put it as generously as possible, it’s not subtle…
Independent Journal Review, citing a “Republican Senate aide,” reports what would be the most incredible package of carve-outs known to mankind. It would allow Alaska—and Hawaii, tossed in as a poor effort for political and legal cover—to keep Obamacare in the Obamacare repeal bill. And then some.” (F)

“The bill would allow states to opt to waive Obamacare rules requiring basic health benefits, essentially cutting protections for sick people in an effort to keep premiums from rising. The waivers allow states to charge more for health insurance offered to people with pre-existing conditions—including cancer, heart disease, Alzheimer’s (or dementia), cerebral palsy and even pregnancy, among other medical factors that could have resulted in denied coverage prior to Obamacare—while continuing to receive federal block grant funding.
Experts say the bill could raise health care costs for those with pre-existing conditions to a point where insurance would be virtually unaffordable for millions of people.” (G)

“When Iowa reporters asked Sen. Chuck Grassley on Wednesday about the attempt to repeal and replace Obamacare, his answer was remarkable and revealing.
“You know, I could maybe give you 10 reasons why this bill shouldn’t be considered,” the Iowa Republican said. “But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.” (H)

“The bill is structured as a sort of slow-motion repeal of the health law’s main coverage programs. Though the bill establishes the new state block grant program for a decade, all of the program’s money expires after 2026. That makes it different from the Obamacare overhaul bill passed by the House and a previous bill considered by the Senate, which would have made modifications and cuts to those programs, but preserved them in perpetuity. The expiration of the health law’s programs alone would probably mean that about 23 million fewer Americans would have health coverage, if compared with current law, according to an estimate the Congressional Budget Office made in regard to a previous repeal bill.” (I)

(A) Trump Is Misrepresenting What’s In The Health Care Bill He Wants To Pass, by Marina Fang, http://www.huffingtonpost.com/entry/trump-graham-cassidy-health-care-bill_us_59c3a74ee4b0c90504fbdcd7
(B) Like Other ACA Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize Individual Market, by JACOB LEIBENLUFT EDWIN PARK MATT BROADDUS AVIVA ARON-DINE, https://www.cbpp.org/research/health/like-other-aca-repeal-bills-cassidy-graham-plan-would-add-millions-to-uninsured
(C) GOP senator admits new healthcare bill could harm people with preexisting conditions, but says it won’t happen, by Bob Bryan, https://finance.yahoo.com/news/gop-senator-admits-healthcare-bill-160014682.html
(D) Graham-Cassidy Is the Worst Obamacare Repeal Bill Yet, by Thomas Huelskoetter, http://fortune.com/2017/09/20/graham-cassidy-health-care-bill-obamacare-repeal/
(E) What Graham-Cassidy means for pre-existing conditions, by Caitlin Owens, https://www.axios.com/what-graham-cassidy-really-means-for-pre-existing-conditions-2487720743.html
(F) Report: GOP Is Trying to Buy Murkowski’s Obamacare Repeal Vote by Letting Alaska Keep Obamacare, by Jim Newell, http://www.slate.com/blogs/the_slatest/2017/09/21/murkowski_buyoff_watch_senate_gop_may_just_let_alaska_keep_obamacare.html
(G) TRUMP FALSELY CLAIMS AMERICANS WITH PRE-EXISTING CONDITIONS ARE GUARANTEED COVERAGE UNDER NEW HEALTH BILL, by CHRIS RIOTTA, http://www.newsweek.com/donald-trump-pre-existing-conditions-health-care-graham-cassidy-false-669001
(H) How one Chuck Grassley quote sums up the entire GOP repeal and replace effort, by Chris Cillizza, http://www.cnn.com/2017/09/21/politics/grassley-trump-health-care/index.html
(I) How the Latest Obamacare Repeal Plan Would Work, by REED ABELSON and MARGOT SANGER-KATZ, https://www.nytimes.com/2017/09/20/upshot/obamacare-repeal-bill-offers-both-enormous-flexibility-and-uncertainty.html

“Eleven governors, including five Republicans and a pivotal Alaskan independent, urged the Senate on Tuesday to reject a last-ditch push to dismantle the Affordable Care Act.
But Republican leaders pressed toward a showdown vote. And they choked off separate bipartisan efforts to shore up health insurance markets under the Affordable Care Act, hoping to give Republican senators no alternative but to vote for repeal.
The latest repeal bill, drafted by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, would undo much of the Affordable Care Act and send tens of billions of federal dollars to the states with vast discretion over how to spend the money.” (A)

“On Tuesday evening, Sen. Lamar Alexander (R-Tenn.), the chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee, said that he was ending bipartisan negotiations for a bill to stabilize health insurance markets and make a few changes to the Affordable Care Act, because after four hearings and involved negotiations, his group had “not found the necessary consensus among Republicans and Democrats.” The unexpected decision appears aimed at shoring up support for the Senate GOP’s last-ditch plan to repeal ObamaCare, sponsored by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), by removing any alternative legislation….Alexander said that especially since Graham-Cassidy gained steam, appetite within his party for his bill was very low. “I know how to get bipartisan results, but I’m not a magician,” he said. (B)

“.. Like a bad sequel to a terrible movie, a proposal whose main architects are Bill Cassidy of Louisiana and Lindsey Graham of South Carolina would in many ways be worse than bills that came before it..
It is hard to overstate the cruelty of the Graham-Cassidy bill. It would eliminate the mandate that even healthy people buy health insurance, end the subsidies that help people purchase coverage and stop the expansion of Medicaid. It would offer states block grants they could use to help people get insurance but would leave people at the mercy of individual state legislatures and, over all, would provide $239 billion less than what the federal government would spend under current law between 2020 and 2026, according to the Center on Budget and Policy Priorities. (C)

“…With a deadline of Sept. 30 looming for use of the reconciliation rules to pass a bill, the Congressional Budget Office announced that it would rush analysis of the current overhaul bill, called Graham-Cassidy after its two primary sponsors, by the beginning of next week. That analysis would include an assessment of whether the bill would increase deficits over the long term, which is necessary for reconciliation. But it wouldn’t go much further.
“CBO will provide as much qualitative information as possible about the effects of the legislation,” its announcement read, “however CBO will not be able to provide point estimates of the effects on the deficit, health insurance coverage, or premiums for at least several weeks.” (D)

“Gov. Chris Christie said on Wednesday that he opposes the latest Senate plan to repeal and replace Obamacare, deeming it “too injurious” to New Jersey. “I oppose Graham-Cassidy because it is too injurious to the people of New Jersey,” …I’m certainly not going to support a bill that takes nearly $4 billion from people in the state.” New Jersey could lose around $3.9 billion in federal Medicaid funds by 2026, according to an estimate from the Center for Budget and Policy Priorities.
Christie, an early and ardent supporter of President Donald Trump, stressed that he remains “philosophically” opposed to Obamacare but “took advantage” of Medicaid expansion for the benefit of his state residents….The Republican governor said he agreed with the “concept of block grants” but felt that Graham and Cassidy were “tying themselves into knots trying to help the states that didn’t expand.”” (E)

Health insurers will receive this month’s payments from the Trump administration reimbursing them for reducing copayments and deductibles for millions of low-income customers, the White House said Tuesday, once more shelving a standoff with insurers over the contested funds. (F)

“Graham said Tuesday he has made an alliance with “Darth Vader” — referring to former Trump advisor Steven K. Bannon — for support to see the bill to passage. Bannon, who was portrayed as the villain on NBC’s “Saturday Night Live,” is back to running the website Breitbart, which is influential among conservatives, after being pushed out of the White House.
“I have got Alan Greenspan, Jeb Bush and Steve Bannon” behind this bill, Graham said. “If anyone can do better, I’d like to meet them.”” (G)

(A) Republican Leaders Defy Bipartisan Opposition to Health Law Repeal, by ROBERT PEAR and THOMAS KAPLAN, https://www.nytimes.com/2017/09/19/us/politics/obamacare-act-fix-collapses-repeal-trump.html?_r=0
(B) Senate Republicans pull out of bipartisan health-care talks as Graham-Cassidy picks up steam, http://theweek.com/speedreads/725690/senate-republicans-pull-bipartisan-healthcare-talks-grahamcassidy-picks-steam
(C) The Republican Health Care Zombie Is Back, https://www.nytimes.com/2017/09/19/opinion/editorials/republican-healthcare-graham-cassidy.html
(D) Reminder: It’s very unusual to vote on a health-care bill before Congress knows what it will do, by Philip Bump, https://www.washingtonpost.com/news/politics/wp/2017/09/19/reminder-its-very-unusual-to-vote-on-a-health-care-bill-before-congress-knows-what-it-will-do/?utm_term=.7f33e17cf9b4
(E) Christie says he opposes Graham-Cassidy bill, by KATIE JENNINGS, http://www.politico.com/states/new-jersey/story/2017/09/20/christie-says-he-opposes-graham-cassidy-obamacare-replacement-bill-114611
(F) Trump Administration Makes ACA’s Health-Insurer Payments for September, by Louise Radnofsky, https://www.wsj.com/articles/trump-administration-makes-acas-health-insurer-payments-for-september-1505855468
(G) Trump is all in for GOP healthcare bill; sponsor Graham allies with ‘Darth Vader’ (a.k.a. Steve Bannon) for support, by Lisa Mascaro, http://www.latimes.com/politics/washington/la-na-essential-washington-updates-trump-all-in-for-gop-healthcare-bill-1505841753-htmlstory.html

“The Congressional Budget Office says it won’t be able to provide crucial projections about the impact of the newest Republican (health care) bill….until after the Senate is expected to vote on it.”
“House Speaker Paul Ryan says he is encouraging every Republican senator to vote for the latest, last-ditch effort in the Senate to dismantle Barack Obama’s health care law….Due to Senate deadlines, there would be no time for the House and Senate to try to work out their differences. The House backed a bill in May that went nowhere in the Senate. Ryan signaled that he would try to get the House to pass the Senate bill….
The nonpartisan CBO tweeted Monday that it would take “at least several weeks” to estimate the measure’s effect on the number of people covered and insurance customers’ premiums. That is crucial information for GOP senators trying to determine how the proposal would affect their states and whether to support the legislation.” (A)

“In a new Republican effort to repeal the Affordable Care Act, Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana have released a plan that would essentially allow states to come up with their own health care plans using a federal block grant….
Like earlier Republican health care overhaul bills, the new bill would also make permanent, structural changes to the Medicaid program for beneficiaries who qualified before the expansion, converting it from an open-ended federal health care program to one that caps federal spending on each beneficiary. (B)
To see “How the bill would alter major parts of Obamacare” highlight and click on https://www.nytimes.com/interactive/2017/09/18/us/cassidy-graham-health-plan-aca-repeal.html

“In reality, Graham-Cassidy is the opposite of moderate. It contains, in exaggerated and almost caricature form, all the elements that made previous Republican proposals so cruel and destructive. It would eliminate the individual mandate, undermine if not effectively eliminate protection for people with pre-existing conditions, and slash funding for subsidies and Medicaid. There are a few additional twists, but they’re all bad — notably, a funding formula that would penalize states that are actually successful in reducing the number of uninsured.” (C)

“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.” (D)

“Republican leaders are now trying to determine whether they have enough votes to begin debate on the bill, according to Senate aides. They are also trying to get Sen. John McCain, R-Ariz., whose “no” vote sank the most recent Republican health-care bill in July, fully on board…
“Why did Obamacare fail? Obamacare was rammed through with Democrats’ votes only. … That’s not the way to do it. We’ve got to go back. If I could just say again, the way to do this is have a bill, put it through committee,” he said on CBS’s “Face the Nation.”
Senate Republicans have a very slim path to victory on Graham-Cassidy: If more than two Republicans vote no, the bill won’t pass. The math became even harder once Sen. Rand Paul, R-Ky., announced his opposition Friday.” (E)

“President Donald Trump would sign the Graham-Cassidy bill if the legislation to repeal Obamacare makes it to his desk….”
“Collins, the Maine Republican who voted against a repeal bill earlier this year, said that she has a “number of concerns,” including the fact the bill would restructure Medicaid in a fundamental way without considering the ramifications. For Maine, it would be $1 billion less funding over a decade, she said. People would preexisting conditions would also be hurt.
“It seems to have many of the same flaws of the bill we rejected previously and in fact, it has some additional flaws because there’s some language that leads me to believe that people worth preexisting conditions would not be protected in some states,” Collins said….”It’s difficult not having a CBO analysis to rely on,” she noted.” (F)

(A) The Latest: Ryan rooting for Senate GOP health care overhaul, By THE ASSOCIATED PRESS, http://abcnews.go.com/Health/wireStory/latest-budget-office-time-health-bill-49937099
(B) The Latest Health Care Repeal Plan Would Give States Sweeping Discretion, by HAEYOUN PARK and MARGOT SANGER-KATZ, https://www.nytimes.com/interactive/2017/09/18/us/cassidy-graham-health-plan-aca-repeal.html
(C) Complacency Could Kill Health Care, by Paul Krugman, https://www.nytimes.com/2017/09/18/opinion/health-care-graham-cassidy.html?_r=0
(D) ACA repeal in 11 days? 10 things to know Tuesday about the Graham-Cassidy bill, by Leo Vartorella, http://www.beckershospitalreview.com/hospital-management-administration/aca-repeal-in-11-days-10-things-to-know-tuesday-about-the-graham-cassidy-bill.html
(E) Senate Republicans fast-track last-ditch Obamacare repeal, by Elise Viebeck and David Weigel, http://www.chicagotribune.com/news/nationworld/politics/ct-gop-aca-repeal-20170917-story.html
(F) Trump, White House go all-out for Graham-Cassidy Obamacare repeal bill, by Kaitlan Collins, http://www.cnn.com/2017/09/19/politics/trump-graham-cassidy-obamacare-repeal/index.html

“Liberals and conservatives in Congress were planning on Wednesday to set forth two radically different proposals for health care: a huge expansion of Medicare, which would open the program to all Americans, and a rollback of the Affordable Care Act, which would give each state a lump sum of federal money with sweeping new discretion over how to use it….
Senator Bernie Sanders of Vermont, the onetime candidate for the Democratic presidential nomination, proposed what he called “a Medicare-for-all, single-payer health care system,” and he said 15 Democratic senators supported it….
At the same time, several Republican senators, led by Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, unveiled their bill, which would take money spent under the Affordable Care Act and give it to states in the form of block grants.” (A)

“Sen. Bernie Sanders, I-Vt., unveiled his Medicare-for-All bill Wednesday, with over a dozen Democratic senators coming out in support of the proposal, according to CNN….. All Americans would receive a “Universal Medicare card” that would qualify them for all patient services, including hospital stays, dental and vision care, hearing aids, substance abuse treatment and abortion.
The proposal would be phased in over a four-year period. In the first year, the Medicare eligibility age would be lowered to 55 and all children under 18 would also be eligible. Coverage would grow to include dental, vision, reproductive health and behavioral health coverage. The next year the eligible age would drop to 45, 35 the year after that and then finally cover every citizen by the fourth year. (B)

“..Graham and Cassidy have been shopping versions of their bill for months now, and submitted a detailed version as an amendment in July. As it stands, the legislation would make it virtually impossible for dozens of states to continue operating Obamacare as we know it without kicking in unrealistic amounts of their own money. That’s because, in the short term, the law is designed to penalize states that embraced the ACA while rewarding those that resisted it. Further down the line, the legislation simply zeroes out all of Obamacare’s spending, a de facto repeal of the entire program that doesn’t include a replacement. As policy, it’s a bit like walking into somebody’s house, lighting the whole ground floor on fire, then telling them, “Hey, you can keep living here—if you like it.” “ (C)

“President Trump promised Thursday to veto legislation for a single-payer, government-run health care system. “Bernie Sanders is pushing hard for a single payer healthcare plan — a curse on the U.S. & its people,” the president tweeted. “I told Republicans to approve healthcare fast or this would happen. But don’t worry, I will veto because I love our country & its people.”
There’s just one major thing to remember about this promise: He’ll never get the chance to veto the bill, because it’s never going to reach his desk during this current session of Congress. “ (D)

“Lawmakers hope to pass bipartisan legislation to steady the individual insurance market, but health plan officials aren’t optimistic that a solution will come in time for them to make strategic business decisions.
Those subsidies help lower the out-of-pocket costs for consumers with incomes below 250% of the federal poverty level. Without them, insurers will likely hike rates by as much as 20%, or stop offering coverage on the exchanges altogether. Some states are publicly releasing approved 2018 rates, while others are waiting for a signal from the Trump administration that it will pay the subsidies through next year.
The notion of funding the cost-sharing reduction subsidies is gaining momentum. Sen. Lisa Murkowski (R-Alaska), a swing vote who helped kill a partial repeal of the ACA, said what matters when it comes to appropriating money for the subsidies is that both parties agree it should be done. “Whether it’s one year, two years or perhaps longer, we can figure that out,” she said.” (E)

In his opening statement, Senator Orrin Hatch (R-UT), the (Senate Finance) committee chair, blasted the ACA, saying that it hadn’t reined in costs and was driving up premiums for many people who buy insurance on the state exchanges. He was dubious about the idea of trying to fix the law.
Alluding to the cost-sharing subsidies that some experts believe must be paid to insurers to stabilize the exchanges, he said, “In my view, an Obamacare bailout that is not accompanied by real reforms would be inadvisable. We can’t simply invest more resources into a broken system and hope that it fixes itself over time.” (F)

“A senior Democratic aide told The Hill that some Democrats in the Senate’s Health, Education, Labor and Pensions (HELP) committee are concerned that the GOP members may be trying to pull the bipartisan negotiations in a more conservative direction. The committee is hoping to hammer out a deal by the end of the week.
“Republicans appear to be pulling the negotiations in a more partisan direction from their side by pushing changes that Democrats have made clear from the start they wouldn’t agree to—like rolling back protections for patients with pre-existing conditions,” ..” (G)

“I asked six of these Obamacare opponents, policy experts at conservative and libertarian think tanks, what they learned from the spectacular failure of Obamacare repeal and what they think happens now, in this strange new reality we all occupy…
Roy described his ideal end state as one similar to the Swiss system: Universal coverage, through private insurance and subsidization, but without that country’s individual mandate or overly prescriptive federal mandates for benefits.
Still, there were some shared visions. Any wonk on the right will talk about equalizing the tax code by capping the unlimited tax break for employer-based insurance and dramatically expanding health savings accounts. Everybody wants more power returned to the states. Everybody is concerned about reining in the costs of the Medicare and Medicaid programs over the long term.” (H)

Bipartisan teams in the Senate and House are separately taking important first steps toward fixing the nation’s individual health insurance market.
Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), as well as some representatives in the House, are looking at ways to improve and strengthen state innovation waivers, which already exist in the Affordable Care Act (ACA), or ObamaCare. Also known as Section 1332 waivers, they give states flexibility to bypass some of the law’s requirements and to help develop localized ways to lower health-care costs, broaden coverage and improve treatment in their states.
Expanding this flexibility, which we have written about before, could be the key to unlocking some of the partisan gridlock surrounding health-care reform. If strengthened, these waivers could help governors and state legislatures across the nation innovate and find health insurance solutions that work best for their states. More conservative states could pursue market-oriented reforms, while more liberal states could pursue their own models. (I)

“Democrats desperately needed the Affordable Care Act to thrive while they still controlled the White House. But with President Barack Obama gone, and GOP majorities in the House and Senate, they’re pretty much off the hook — at least, according to polls showing 60 percent of Americans find Republicans responsible for the ACA.
As for Republicans, they’re still deeply bitter they weren’t able to repeal one iota of Obamacare despite their high-drama effort over the spring and summer. Many members have spent too many years characterizing the extra Obamacare subsidies now at stake as improper insurer “bailouts” to get excited about funding them, even though providing them could somewhat improve otherwise skyrocketing rates next year.” (J)

CBO directly contradicts the claim that Obamacare is in a death spiral: “The nongroup health insurance market to be stable in most areas of the country. Preliminary data for 2018 show that insurers will offer coverage in all or almost all areas. Although premiums have been increasing, most subsidized enrollees buying health insurance through the marketplaces are insulated from those increases because their out-of-pocket payments for premiums are based on a percentage of their income; the federal government pays the difference between that percentage and the premium for a benchmark plan.” Remarkably, only “one-half of one percent of people in the country” will live in areas with no individual group insurers. Interestingly, now that Obamacare is here to stay, CBO expects that “over time” more states will expand Medicaid.
CBO does find some problems — caused by the uncertainty this administration created….” (K)

“Senators on the health committee are working over the weekend to try to reach an agreement on a stabilization bill for Obamacare that they hope will temper insurer exits and premium increases expected for customers who will buy coverage on the exchanges….
“It’s going to be a tough needle to thread for both sides,” a senior GOP aide told the Washington Examiner. “We got a clear indicator on actually how interested many Democrats are in a bipartisan solution for healthcare when 17 of them introduced single payer this week.”
Like many Republicans, Democrats have not indicated whether they would sign on to a stabilization package, and many of them have laid the stability of the exchanges at the feet of Trump, who has not said whether he would fund cost-sharing reduction subsidies, a part of Obamacare they have said he must pay.” (L)

“Having failed to repeal Obamacare, President Donald Trump has said his strategy would be to let the health law “implode.” The Congressional Budget Office released a report Thursday that predicts Trump administration policies on Obamacare could help it on its way by leading to rising premiums and decreased enrollment in individual insurance markets over the next year.” (M)

(A) Medicare for All or State Control: Health Care Plans Go to Extremes, by ROBERT PEAR, https://www.nytimes.com/2017/09/13/us/politics/health-care-obamacare-single-payer-graham-cassidy.html?_r=0
(B) Bernie Sanders’ Medicare-for-All bill: 4 things to know, by Leo Vartorella, http://www.beckershospitalreview.com/hospital-management-administration/bernie-sanders-medicare-for-all-bill-4-things-to-know.html
(C) Republicans Claim That Their New Plan to Repeal Obamacare Is a Moderate Compromise. LOL., by Jordan Weissmann, https://slate.com/business/2017/09/the-new-republican-plan-to-repeal-obamacare-is-even-more-vicious-than-the-old-plan.html
(D) Trump promises to veto Bernie Sanders health care bill that will never reach his desk, by Jessica Estepa, https://www.usatoday.com/story/news/politics/onpolitics/2017/09/14/trump-promises-veto-bernie-sanders-backed-health-care-bill-never-reach-his-desk/667456001/
(E) Left in the lurch: Ongoing uncertainty is taking a toll on health insurers, by Mara Lee and Shelby Livingston, http://www.modernhealthcare.com/article/20170909/NEWS/170909887
(F) Senate Hearing on Healthcare Shows Continuing Conflicts, by Ken Terry, http://www.medscape.com/viewarticle/885593
(G) Signs of trouble in Senate’s ACA stabilization talks, by Paige Minemyer, http://www.fiercehealthcare.com/aca/democrats-fear-gop-wants-to-take-senate-healthcare-hearings-a-partisan-direction
(H) Once Obamacare repeal is dead, the GOP has no plan B, by Dylan Scott, https://www.vox.com/policy-and-politics/2017/9/11/16271168/obamacare-repeal-dead-what-now
(I) Gingrich and Daschle: Senate and House making key steps to fix health care, http://thehill.com/opinion/healthcare/350696-senate-and-house-making-key-first-steps-to-fix-health-care
(J) The Health 202: Why Congress might fail to fund extra Obamacare subsidies, by By Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/09/15/the-health-202-why-congress-might-fail-to-fund-extra-obamacare-subsidies/59bada3730fb045176650c73/?utm_term=.58a56a9d5f1a
(K) Three ways to do health-care reform, Jennifer Rubin, https://www.washingtonpost.com/blogs/right-turn/wp/2017/09/15/three-ways-to-do-health-care-reform/?utm_term=.be329bc3a55b
(L) Bipartisan Senate group prepares to present Obamacare fix, by Kimberly Leonard, http://www.washingtonexaminer.com/bipartisan-senate-group-prepares-to-present-obamacare-fix/article/2634607
(M) Trump wanted to hurt the Obamacare markets. The CBO says he’s a success, by Sam Petulla, http://www.cnn.com/2017/09/15/politics/20170915-cbo-insured-rate-uncertainty-premiums/index.html