A ‘near-death’ experience that's good news for patients

In late September, the Affordable Care Act (ACA), otherwise known as Obamacare, came within a vote or two of being repealed by the U.S. Senate. The bill that would have repealed it was a radically bad one that deserved to die. Yet this doesn't mean that Obamacare is safe.

The Graham-Cassidy bill, named after the bill's co-sponsors, Sen. Lindsey Graham (R-SC) and Sen. Bill Cassidy (R-LA), would have replaced the ACA with an alternative that turned most of the responsibility for regulating and financing health coverage to the states, funded in part by block grants from the federal government. Had the bill passed the Senate, it likely would have also passed the House of Representatives.

Yet Obamacare survived this latest near-death experience, one of many since it became law in 2017. Senate Majority Leader Mitch McConnell (R-KY) decided not to go ahead with a planned vote on Graham-Cassidy when it became evident that it would fall one or two votes short of the 50 votes required to pass, even with Vice President Mike Pence ready to cast a tie-breaker if needed. Sen. Rand Paul (R-KY) had announced he was a “no” vote on the bill, and Sen. Susan Collins (R-ME) was expected to join him in opposition. When Sen. John McCain (R-AZ) then announced he could not vote for the bill because of concerns that it was being rushed to a vote, Graham-Cassidy's fate was sealed.

Sen. McConnell's decision to pull Graham-Cassidy meant that 60 votes would soon be required to pass repeal, since the budget reconciliation measure allowing passage by a simple majority expired at the end of September. With Democrats unified against repeal and able to filibuster, and Republicans themselves divided, the ACA appears to be safe from repeal for at least the remainder of 2017.

And that's good news for patients. For all of its known flaws, like lack of adequate insurance competition in many markets, the ACA has extended coverage to millions of Americans. The Graham-Cassidy bill, by contrast, would have taken coverage away from millions. It was fiercely opposed by just about everyone in American health care, from physicians to hospitals to insurers to patient advocacy groups, with the American College of Physicians among those leading the physician opposition to the measure. Had it been enacted, Graham-Cassidy would have radically changed the relationship between the federal and state governments, “the biggest devolution of federal funding and responsibility to states, ever, for anything,” noted Larry Levitt, senior vice president of the Kaiser Family Foundation.

How radical was Graham-Cassidy?

• It would have replaced the ACA's guaranteed federal funding to help people buy coverage in the individual market with optional block grants to the states, with very few federal guardrails on how states might spend their block grant money.
• It would have allowed states to eliminate the ACA's prohibition on exclusion of people with pre-existing conditions, as well as its essential benefit requirements, so that insurers in many states would again be allowed to charge sick people more for their insurance, failing what Sen. Cassidy himself had previously referred to as the “Jimmy Kimmel test.”
• States could also decide to permit insurers to again exclude coverage for treatments that patients need, like chemotherapy, or substance use disorder treatment, or maternity and childbirth benefits, while reimposing annual and lifetime limits on coverage for services no longer considered to be essential by a state.
• It would have ended Medicaid expansion and capped the federal contribution to Medicaid. Federal dollars that had gone to Medicaid-expansion states would have been redistributed to all of the states, resulting in massive losses of money for the expansion states.
• Even with block grants, the federal government's contributions to helping make coverage available and affordable would have been cut by hundreds of billions of dollars over the next 10 years.
• It would have required states to develop an entirely new health care financing system to replace Obamacare by 2020, or lose all dedicated federal dollars that otherwise would have gone to the state as a block grant.

Although Graham-Cassidy is dead, President Donald Trump wants Congress to try again, and an energized core of highly engaged conservative voters and donors will insist that the party not walk away from its seven-year-old promise of repealing Obamacare. Keep in mind that almost all of the Republican members of Congress remain fiercely opposed to Obamacare, and as radical as it was, Graham-Cassidy came within a couple of votes of becoming law. Graham-Cassidy's policies could come back for another vote, at another time. Finally, there is nothing to prevent the GOP leadership from approving a new budget reconciliation measure for FY 2018 or FY 2019 to again allow ACA repeal by a simple majority vote.

Yet getting to a majority for any ACA repeal or replace bill is anything but simple, given the strong opposition from physicians, patients, and other health care advocates; the growing popularity of the ACA and unpopularity of repeal (the latest polls show that most Americans want the ACA improved, not repealed); and continued divisions within Republican ranks on what should replace it. Sen. McConnell and Speaker of the House Paul Ryan (R-WI) may nonetheless try to bring back repeal and replace in 2018, and if they do, it will once again fall to organizations like ACP to try to stop them.

There is another path available to Congress, one that I hope it will take: Work to make the ACA better, not blow it up as Graham-Cassidy would have done. Pass bipartisan legislation to create incentives for health insurers to enter and remain in the individual markets. Offer consumers in all markets a choice of enrolling in a public option, like Medicare. Reinsure health plans against adverse selection. Fund outreach programs to help people enroll.

Obamacare has had more than enough near-death experiences, and although it's (barely) survived each one, the law is battered and bruised, helping many get coverage but falling short for others who find the coverage it offers in some markets unaffordable. It's time for Congress to put aside partisan differences and come together to strengthen and heal Obamacare instead of trying to bring it down.