Top Takeaways from this week – (1) Senate Majority Leader McConnell indicated the Graham-Cassidy Proposal will go to the Senate floor next week; (2) the Senate Finance Committee and the Senate Homeland Security & Governmental Affairs Committees will hold the first hearings on ACA repeal and replacement on Monday and Tuesday; (3) The CBO announced it will only be able to provide a “preliminary estimate” by early next week; and (4) Senate HELP Committee Chair Alexander formally ended his Committee’s work on a bipartisan market stabilization deal.

This week, the Graham-Cassidy proposal amending the Better Care Reconciliation Act gained significant and largely unexpected momentum – there are now two Senate hearings announced and Senate Majority Leader McConnell (R-KY) has promised to bring the bill to the Senate floor– despite the short timeline before reconciliation rules end on September 30. The impending deadline has spurred a jostling for votes, conflicting analyses and projections of the bill’s impact on costs and coverage, and forced the Senate HELP Committee to abandon its weeks-long quest for a bipartisan stabilization bill.

Graham-Cassidy Proposal

Last week, Sens. Graham (R-SC), Cassidy (R-LA), Heller (R-NV), and Johnson (R-WI) released legislative text for their proposal, known as “Graham-Cassidy,” which would amend the Better Care Reconciliation Act (BCRA) to block grant ACA funding to states to develop their own solutions to their healthcare markets. The proposed Market-Based Health Care Grant Program would replace the ACA’s funding structures for Medicaid expansion, premium tax credits, cost-sharing reductions, and basic health plans. Funding for new enrollment Medicaid expansion would end by 2020, and like the BCRA, Medicaid financing would change to per-capita capped payments starting in fiscal year 2020. Press release: FAQ: Section-by-section:  Bill text:

This week, the bill’s backers have projected increasing confidence in the bill’s chances for passage. Coming out of a closed-door GOP caucus lunch on Tuesday, Sen. Graham (R-SC) remarked, “I really believe we’re going to get 50 Republican votes. I’ve never felt better about where we’re at.” Additionally, Senate Majority Leader McConnell (R-KY) announced yesterday that he would bring the bill to the Senate floor for a vote next week – a decision he has said he would only make if he was assured of 50 votes – which  sets up a final deadline for a final decision on ACA repeal.

Procedural Hurdles

There are many hurdles for the bill to overcome to gain the minimum votes required for passage over the next week, including productive hearings, a favorable, if limited, score from the Congressional Budget Office (CBO), and certification from the Senate Parliamentarian that the provisions of the current bill do not violate Senate reconciliation rules. Finally, if the Senate passes the bill in time, it will still need to be considered by the House, where it also faces an uncertain path to passage.

Hearings: Two Senate Committees will hold hearings next week on the Graham-Cassidy proposal. The Senate Finance Committee will convene a hearing on Monday. In a press release, Chair Hatch (R-UT) noted, “Senators have expressed a strong desire to examine the details of the Graham-Cassidy proposal through a public hearing. A hearing will allow members on both sides of the aisle to delve deeper into the policy and gain a better understanding of what the authors hope to achieve.” The Senate Committee on Homeland Security & Governmental Affairs has also announced a hearing for next Tuesday titled “Block Grants: How States Can Reduce Health Care Costs.” Press releases from the Chair and Ranking Member: and

Congressional Budget Office Score: Senate leadership has been in discussion with CBO to fast-track their review of the legislation, and on Monday CBO announced that it is “aiming to provide a preliminary assessment of the Graham-Cassidy bill by early next week,” which will include analyses of whether the legislation would reduce deficits by at least as much as the American Health Care Act, but will not include “point estimates on the effects on the deficit, health insurance coverage, or premiums for at least several weeks.”  Democratic Congressional leaders have written to CBO Director Hall requesting a “comprehensive CBO analysis,” arguing such a review is essential before Congress votes on the bill. In the absence of a CBO analysis, several health care groups have released their own projections of the bill’s impact on cost and coverage. CBO Statement: Democratic Letter: Projections: and and

Senate Parliamentarian Review: The Senate Parliamentarian has yet to rule on whether any parts of the rule are inadmissible under Senate reconciliation rules. In July, the Parliamentarian determined that several provisions of the Better Care Reconciliation Act, on which the Graham-Cassidy bill is based, violated the rules, including provisions that would defund Planned Parenthood, eliminate funding for cost-sharing reductions, and change the ACA’s age-rating rules, among others. Summaries of the Parliamentarian’s Findings: and

House Passage: House Speaker Ryan (R-WI) has committed to passing the Graham-Cassidy bill without changes, once the Senate has successfully passed it. However, while the House was able to successfully pass the American Health Care Act in July, it did so on a razor thin 217-213 margin.

House Freedom Caucus Chair Meadows (R-SC) has noted that this effort is “fundamentally our last chance to make a legislative fix to Obamacare, and if it doesn’t happen, then the chances of it happening in the future are slim to none. And so I fully expect that if it makes it out of the Senate, the pressure will be so great – from moderates to conservatives – to get it passed.”

Despite such pressure, several centrist Republicans have raised concerns with the bill, given that the amendment would have more acute budgetary impacts to certain states that have expanded Medicaid and/or have high healthcare spending, like New York or California, which may deter Republicans representing districts in those states.

Support for the Bill

On Wednesday, Senate Judiciary Chair Grassley (R-IA) encapsulated the challenges for Sens. Cassidy, Graham, Heller and Johnson in gathering support for their bill when he remarked, “I could maybe give you 10 reasons why this bill shouldn’t be considered. 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.”

The cosponsors have said that they have at least 48 votes confirmed, but there are a number of Republican Senators who remain either opposed or who are still considering the bill’s impacts on their states. Additionally, a number of Republican Governors and other stakeholders have spoken out against the bill.


  • Key Senators
    • Paul (R-KY) is a “no.” He has stated, “I’m actually happy to be out there as the leading advocate for repealing Obamacare, not keeping it.”
    • Collins (R-ME) has said she has a “number of concerns” with the bill, and wants to review the CBO’s analysis before making a decision.
    • Murkowski (R-AK) today said, “What I’m trying to figure out is the impact to my state. There are some formulas at play with different pots of money with different allocations and different percentages so it is not clear” how Alaskans would be affected. She further indicated that she would take Governor Walker’s opinion into account in reaching a decision.
    • McCain (R-AZ) has signaled that he does “not yet” support the proposal due to procedure concerns, namely that he believes that any health care legislation should go through normal Senate processes, including Committee hearings and floor debate.
    • Other Senators, like Finance Committee Chair Hatch (R-UT) have noted concern that the bill either does not go far enough to repeal the ACA’s taxes,
  • Governors
    • On Tuesday, a group of 15 Republican governors urged congress to back the Graham-Cassidy bill, noting that “adequately funded block grants to the states, along with maximum flexibility and control, is the best option on the table.” Arizona Gov. Ducey (R) has also announced his support for the bill.
    • However, a bipartisan group of 10 governors, including Govs. Sandoval (R-NV) and Walker (R-AK) also sent a letter urging Congress “not to consider the Graham-Cassidy-Heller-Johnson amendment and renew support for bipartisan efforts to make health care more available and affordable for all Americans.” Letter:
    • Republican Governors Hogan (R-MD), Christie (R-NJ), and Martinez (R-NM) have also came out against the Graham-Cassidy bill.
  • Healthcare Stakeholders: A number of stakeholder groups have also written to Congressional leaders expressing concern over the bill and its potential impacts on coverage and access to care.
    • Health Plans – Blue Cross Blue Shield, AHIP, Alliance of Community Health Plans, and Kaiser Permanente all released statements against the bill. BSBCA statement: AHIP Statement: KP Statement:
    • Provider Groups – on Tuesday, the American Medical Association wrote to the Majority Leader and Minority Leader expressing their opposition to the Graham-Cassidy bill and urging the Senate to “reject any other legislative efforts that would jeopardize health insurance coverage for tens of millions of Americans.” The American Hospital Association noted in a statement that “We believe that coverage could be at risk for tens of millions of Americans…this proposal would erode key protections…and does nothing to stabilize the insurance market now or in the long term.” Another letter from AAFP, AAP, ACP, ACOG, AOA and APA also opposes the bill. AMA Press release and letter: and AHA Statement: Provider letter:
    • Patient Groups – 16 organizations, including the American Cancer Society, the American Heart Association, and the March of Dimes sent a letter opposing the bill on Monday. On Tuesday, the AARP also wrote a letter opposing. Letters: and


Market Stabilization –

Meanwhile, the efforts by the Chair and Ranking Member of the Senate HELP Committee to pass a narrow and bipartisan bill to help immediately stabilize the insurance markets has taken an official backseat to the larger question of the Graham-Cassidy bill.

In addition to pressure from Republican Senate leadership, the White House and House Speaker Ryan (R-WI) on Tuesday announced their opposition to the bipartisan plan to stabilize the ACA’s marketplaces.

The same day, Senate HELP Committee Chair Alexander (R-TN) formally ended his Committee’s work on legislation to shore up the individual marketplaces, noting that he has “not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders’ hands that could be enacted.” Press release:

In response, Ranking Member Murray (D-WA) remarked, “I am disappointed that Republican leaders have decided to freeze this bipartisan approach and are trying to jam through a bipartisan Trumpcare bill, but I am confident that we can reach a deal if we keep working together – and I am committed to getting that done.” Press release:

Administrative Action –

On Tuesday, the White House announced that it will make cost-sharing reduction payments for the month of September, continuing its month-to-month decision making on the issue. In a statement, the Administration noted that “No final decisions have been made about future CSR payments. We are weighing our options and still evaluating the issues.”

Yesterday, CMS released an updated Health Insurance Exchanges Issuer County Map, which shows that nationwide no counties are expected to be bare, but 1,524 counties are expected to only be covered by one issuer. Press release:  Map: