WASHINGTON — For months, Louisiana Senator Bill Cassidy has poured his time into possible replacements for the Affordable Care Act. And he's continued to plug away, even after most other Republicans moved on to other priorities after this summer's dramatic defeat of their proposal to overhaul Obamacare.
A deadline for Republicans to undo the healthcare law on a party-line vote in the Senate, widely viewed as their only shot at repeal, looms at the end of the month. The exact language of Cassidy’s plan remains a work in progress. Meanwhile, some of his Republican colleagues have sounded skeptical notes about its chances.
Yet Cassidy, who plans to unveil a new draft of the bill he’s been writing with Sen. Lindsey Graham of South Carolina on Monday, struck an optimistic note in an interview this week.
“Obviously we have a great idea,” Cassidy said Thursday, a day after meeting with Vice President Mike Pence to discuss the plan. That same day White House adviser Kellyanne Conway told Fox News that President Donald Trump would sign the law if passed by Congress.
The core of Cassidy’s “great idea” is to redirect billions of federal dollars in Medicaid expansion funding and Obamacare insurance subsidies into massive block grants to states, giving governors and state legislatures wide latitude to shape the health insurance markets — and the scope of coverage for poor and low-income residents — within their borders.
Governors love flexibility, Cassidy said in a nod toward his latest strategy to drum up support for his and Graham’s push: selling it to state-level leaders.
About a dozen governors have publicly signaled support for the idea, Cassidy said, which he hopes will be key in building support with those states' senators. Cassidy also spent part of Wednesday drumming up interest in the plan among state insurance commissioners.
“Every one of them said they’d like to have more flexibility and less oversight,” Cassidy said of his discussions with insurance commissioners. “Every one of them.”
Louisiana’s governor, Democrat John Bel Edwards, isn’t among those backing the bill. Edwards’ deputy chief of staff, Richard Carbo, said the governor met with Cassidy for several hours recently to discuss the latest proposals but that Edwards still has a number of open questions about the plan and hasn’t taken a position.
Not everyone watching the healthcare debate is enamored with the core of Cassidy and Graham’s proposal.
Though details of the latest version of the Cassidy-Graham plan haven’t been publicly revealed yet, a version put forward in July met with criticism from a number of quarters because of provisions that would cap federal spending on Medicaid, something opponents have said would amount to significant cuts to government-supported healthcare for the poor, elderly and disabled.
Jeanie Donovan, a health policy analyst for the Louisiana Budget Project, which advocates for low and moderate-income families, said she has a number of concerns about the plan based on the details made public so far.
Federal block-grant funding won't keep up with rising medical costs or changes in population and poverty rates, Donovan said, meaning down the roads states are likely to experience deep funding cuts when compared with the current law.
Just as concerning, Donovan said, was that the plan doesn't require states to put the money toward programs for low-income residents.
Cassidy, however, said he’s substantially reworked the bill in the months since it was rolled out. The original formula to divvy up federal healthcare money between states, Cassidy said, had been drafted by the White House and has since been replaced with another formula that the senator said has proved more popular with state-level leaders.
Cassidy has previously described Medicaid as a "black hole" for tax dollars that would crowd out other essential spending priorities without curbs on its growth. An earlier draft of the plan would cap federal spending on Medicaid while limiting the growth of the block grants.
But given the rapid rise in the cost of healthcare, Cassidy said dramatically cutting the price of health insurance would ultimately require a much broader approach to overhauling the country's healthcare system.
"Fundamentally, to lower the cost of health insurance, you have to lower the cost of healthcare," Cassidy said. "That’s beyond the scope of what we’re doing with this bill but, believe me, I’m thinking very seriously about that."
Even if Cassidy and Graham can pull together enough votes for their plan in the Senate — Cassidy said last week they’re getting close — numerous legislative hurdles for the bill remain.
A full analysis of the latest version of the Cassidy-Graham plan is expected in the coming weeks. Cassidy said he hoped to have a score on the proposal by the nonpartisan Congressional Budget Office in about two weeks. The CBO score should provide an estimate of how many people would be insured by the proposal as compared to the existing law.
Cassidy also said he’s hoping to hold hearings on the bill, something that didn’t happen in the U.S. Senate during previous Republican efforts to replace Obamacare in July. Sen. John McCain, R-Arizona, cited the lack of hearings as a major reason for joining two other Republicans — Sen. Lisa Murkowski of Alaska and Sen. Susan Collins of Maine — in casting a decisive “no” vote that doomed that attempt. With a 52-member majority, Republicans need to get 50 votes, plus the support of the vice president — who serves as a tiebreaker in the Senate — to pass a bill.
“I think we’ll have hearings,” Cassidy said.
Cassidy said he’d discussed his latest plan with McCain, who indicated he might support the bill if it goes through regular hearings.
All that takes time, though, and with a hard Sept. 30 deadline looming, a number of Cassidy’s colleagues expressed doubts that the bill could make it through. Senate Republicans hoped to repeal Obamacare under a process known as reconciliation, which allows them to pass a replacement bill with a bare majority instead of the chamber's usual 60-vote threshold on controversial measures.
But their authority to use the reconciliation process expires on Sept. 30 and Senate leaders have already indicated that they plan to use the next reconciliation process to tackle tax reform, not health insurance.
“I don’t think there’s much of a chance,” Utah Sen. Orrin Hatch, the chairman of the Senate Finance Committee — which would potentially hold hearings on the bill — told McClatchy newspapers.
“I don’t believe so,” Senate Majority Whip John Cornyn, R-Texas, responded when asked by reporters whether a vote might happen before the deadline.
Meanwhile, Sen. Lamar Alexander of Tennessee, the chairman of the Senate health committee, began holding hearings last week on a bipartisan effort to shore up Obamacare’s insurance exchanges.
If some might be stacking the betting odds against Cassidy and Graham’s last-ditch bid to repeal and replacement Obamacare, though, neither have sounded discouraged.
Cassidy has described their plan as his party’s lone remaining shot at fulfilling years of promises to scrap the former president’s signature achievement.
Graham, in an interview with McClatchy newspapers this week, said the alternative — letting Obamacare stand despite a Republican president and majorities in both chambers of Congress — amounts to a grim prognosis for the party.
“You want to kill the Republican party?” Graham said. “You want to have us divided forever? Walk away from the promise to repeal and replace Obamacare without taking your best shot.”