The Gory Details of the GOP’s latest Obamacare repeal

The first result on a Google image search for “gory details” is kind of an apt metaphor here.

The Republican party has until September 30th to push through a repeal of the Affordable Care Act. So far, efforts to find consensus, even among Senate Republicans, have failed. The Cassidy-Graham proposal represents the latest, and likely last, attempt at a repeal. Details and analysis on the bill are still emerging, but what we know so far paints a bleak picture.

What’s In The Bill

The Cassidy-Graham proposal is a collection of ammendments, strike-outs, and insertions. Reading it is akin to reading comments on an essay without the actual essay text. As a result, working out the meaning of the provisions takes a bit of work.

32 Million Uninsured

The bill will end the ACA’s individual and employer mandates as well as federal subsidies for individual insurance. In 2026 the proposal would also end Medicaid expansion funding. The Congressional Budget Office has already estimated similar provisions would cause 32 million Americans to lose health insurance coverage.

Deep Cuts To Medicaid

The ACA expanded Medicaid substantially but a later Court decision gave states the option to opt-out of the expansion. The Cassidy-Graham proposal takes the money going to the states that opted in and distributes it in “block grants” among all of the states. This has the effect of punishing states that embraced the ACA and enriching those that did not. In 2026 funding for the Medicaid expansion would end entirely and the $300,000,000,000 shortfall would be left to the states to cover.

An Attack On Women’s Health

Despite long-standing federal laws preventing the use of federal tax dollars in the funding and financing of abortion, Cassidy-Graham, like other ACA repeal bills that came before it, institutes a one year freeze on Medicaid reimbursements for Planned Parenthood. Individual states may also redefine what constitutes an “essential health benefit” to slash coverage of maternity services and further prevent women’s clinics (like Planned Parenthood) from charging Medicaid for services like cancer screenings and birth control.

Massive Premium Hikes

Under the Cassidy Graham proposal insurers will be able to double their surcharge on elderly customers. Presently the ACA allows insurers to charge older customers three times as much as younger ones. Under Cassidy-Graham this multiplier would be increased to allow rate five-times what younger customers face.

A Return To Healthcare Driven Bankruptcy

Cassidy-Graham brings back “pre-existing” conditions and then some. It not only allows insurers to charge higher rates based on health status, it also repeals language in the ACA which prevents changing insurance rates after a patient is diagnosed with a condition.

As a result, a typical 40-year-old diagnosed with Metastatic cancer would see their health insurance premium jump by 3,500% or an estimated $142,650. Cassidy Graham establishes “invisible risk pools” to help defray this cost. After adjusting for the invisible risk pool the premium increase is only $140,510.

While this is not precisely the same structure as existed before the ACA — patients then were simply unable to buy insurance at any price — few families could afford crippling premiums like those outlined above and the inability to afford insurance is little different than the inability to purchase it.

What’s Not In The Bill

With the end of September closing in, it’s worth noting that this is not the GOP’s first attempt at repealing the ACA. Previous repeal attempts have failed to gather the support of at least 50 of the 52 Republican Senators and the reasons for that failure are evident in the public comments of the dissenting Senators.

A Gradual Medicaid Reduction

Graham-Cassidy doesn’t phase out the Medicaid expansion over 10 years. Instead, it creates gradual reductions up until 2026 before falling off a $200 billion dollar cliff in 2027. That hard transition gives a lot of Republicans heartburn; it invites further legislative tweaking and sets a ticking time bomb in state budgets.

Opioid Funding

Just last month President Trump declared the opioid crisis in a “national emergency” yet there has been almost no motion in the White House or Congress on the topic since then. The opioid epidemic is especially bad in Trump country — those former industrial powerhouse states that delivered the election to Trump in 2016 — and Republican senators from those regions may take issue with that omission. Susan Collins (R-ME) has been particularly vocal on the opioid issue.

Cost and Coverage Estimates

With the deadline fast approaching for a reconciliation-based repeal, the Congressional Budget Office has informed Congress that, while it will be able to make a decision as to the bill’s eligibility for the Reconciliation process, it will not be able to provide estimates on the deficit, insurance premiums, or the number of Americans who will lose health insurance.

Tax Cuts

Taxes are a traditional boogy-man for the Republican Party and the various taxes baked into the ACA are no exception. Republicans — especially Rand Paul (R-TN) — have long cited the ACA’s various tax structures as the most objectionable part of the law. Graham-Cassidy leaves many of these taxes in place in order to comply with budget reconciliation rules.

Tell Congress what you think!

Text RESIST to 50409, or just click here to tell your Representatives or Senators what you think about this or any other issue before Congress

Who to talk to and what to say

If Cassidy-Graham passes the Senate it will probably become law and therefore the Senate is where constituent pressure will have the greatest influence.

If your Senators are Democrats they are likely going to oppose this bill. Your feedback determines how loud they are in denouncing it. More Democratic opposition translates into more news coverage and a higher-intensity media spotlight on the Senate’s last minute push to repeal.

If your Senators are Republicans their adherence to the party line will make or break this bill. The following Republicans are from states which will suffer a cuts to their Medicaid funding if the bill passes

Senators shown in bold were instrumental to the defeat of the GOP’s previous ACA repeal attempt.

Senators marked with a “+” will see Medicaid cuts in excess of $1 billion in 2026.

Lisa Murkowski (R-AK)
Dan Sullivan (R-AK)
John McCain (R-AZ)+
Jeff Flake (R-AZ)+
John Boozman (R-AR)+
Tom Cotton (R-AR)+
Cory Gardner (R-CO)
Marco Rubio (R-FL)+
Todd Young (R-IN)
Chuck Grassley (R-IA)
Joni Ernst (R-IA)
Mitch McConnell (R-KY)+
Rand Paul (R-KY)+
Bill Cassidy (R-LA)+
John N Kennedy (R-LA)+
Susan Collins (R-ME)
Steve Daines (R-MN)+
Dean Heller (R-NV)
Richard Burr (R-NC)+
Thom Tillis (R-NC)+
John Hoeven (R-ND)
Rob Portman (R-OH)+
Pat Toomey (R-PA)
Shelley Moore Capito (R-WV)
Mike Enzi (R-WY)
John Barrasso (R-WY)

A note on Reconciliation

We’ve covered the process details of reconciliation and exactly why the GOP has until September 30th to push through an Obamacare repeal. If you are looking for more on that topic, click here.