Following a sharp rebuke by late-night talk show host Jimmy Kimmel, Sen. Bill Cassidy, R-La., hit the airwaves on Sept. 20 to defend his bill that would undo much of the Affordable Care Act.
The bill, which Cassidy proposed with Sen. Lindsey Graham, R-S.C., was approaching Senate floor consideration when Kimmel took aim at the bill’s impact on some Americans’ ability to secure health insurance.
Under the Graham-Cassidy bill, Cassidy said, "More people will have coverage, and we protect those with pre-existing conditions. (In) states like Maine, Virginia, Florida, Missouri, there will be billions more dollars to provide health insurance coverage for those in those states who have been passed by by Obamacare."
We decided to take a closer look at the way Cassidy described the potential impact of his bill. We found that, according to the best available analysis, Cassidy is not fully accurate about the funding increase.
The bill would establish a new "block grant" program for states, taking the place of funding currently provided under the Affordable Care Act.
The current funding under the ACA is primarily in the form of subsidies for people who purchase plans on the ACA’s online marketplace, as well as an expansion of access to Medicaid.
The bill’s approach holds the potential for state-level cuts in two ways.
First, a block grant is a fixed amount of money, rather than a formula-based entitlement that continues paying even as the number of qualifying beneficiaries rises. So states might have to do more with less.
Second, the bill does not authorize funding for the block grant beyond 2026. While Congress could choose to continue the funding at that point, there is no guarantee that it will. So that leaves a so-called fiscal "cliff" after which funding falls to zero, at least temporarily.
Because the bill would enshrine complex formulas to determine the size of each state’s block grant, individual states would see differently sized block grants.
Generally speaking, the formula is more generous to states that chose not to expand Medicaid under the Affordable Care Act (most of which are Republican-leaning). By contrast, the states that did expand Medicaid (many of them Democratic-leaning) would tend to do less well under Graham-Cassidy, based on various analyses. And if nothing is done to extend funding beyond 2026, all states would feel the pinch.
We would ordinarily turn to the independent Congressional Budget Office to assess this part of Cassidy’s statement like this, but the CBO has said that, given the Republican leadership’s rush to get the Graham-Cassidy bill to the floor, it will be unable to do a full analysis of the bill before the planned vote. (Senate Republicans’ ability to pass the measure with just 51 votes expires at the end of September, which is widely considered the reason for the rush.)
However, on Sept. 20, an outside consulting group, Avalere Health, released an analysis it had conducted of the bill’s potential impact on the 50 states.
Overall, the report concluded that the Graham-Cassidy bill "would significantly reduce funding to states over the long term, particularly for states that have already expanded Medicaid," Caroline Pearson, Avalere’s senior vice president, wrote. It did find that in 16 states, funding would increase, at least as long as the block grants were funded. (The Washington Post’s Philip Bump noted that 15 of these 16 states with an increase voted for Donald Trump.)
As it happens, the four states Cassidy mentioned don’t fare that well in Avalere’s analysis, even though all four decided against accepting the Affordable Care Act’s Medicaid expansion, which should have been an indicator of a relatively benign funding outcome under the law. (In Florida's case, signups on the law's online marketplace have been widespread even as efforts to accept the Medicaid expansion have foundered.)
The following chart summarizes Avalere’s projections for the states Cassidy mentioned, over three different time periods. The figures shaded red denote a decline. The figures shaded green denote an increase.'