On Sunday night, Republican Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana released a new version of their Obamacare repeal bill in a desperate attempt to reach 50 votes before week’s end. By early Monday evening, the bill officially reached three noes, from Sens. John McCain, Susan Collins, and Rand Paul—enough to kill it. Barring a miraculous feat of persuasion, Graham-Cassidy’s 15 minutes have come and gone. Senate Majority Whip John Cornyn told me Monday night that the Republican caucus would discuss how it wanted to proceed during its Tuesday lunch. There might not be anything left to discuss.
Graham-Cassidy 2.0 didn’t have a path to 50 votes. It probably couldn’t even get 48. The revision followed a familiar playbook from Senate health care debates this year: throw money at the more moderate senators and give the conservatives additional deregulation. This failed the same way other iterations of repeal-and-replace had before it: with the moderates still objecting to the meat of the bill despite receiving “sweeteners,” the conservatives never having enough deregulation, and McCain calling the process out for the ugly, rushed spectacle it was.
The new bill was larded up with special enticements for Alaska and its reluctant senator, Lisa Murkowski, though the most controversial of those under consideration—the ability for Alaska to keep its Obamacare subsidies in addition to the block-grant money Graham-Cassidy offers—never made the cut. On the deregulatory side, the bill would no longer require states to apply for waivers to opt out of certain Affordable Care Act regulations—it would just let them write their own rules in certain areas from scratch and describe them to the feds. Cassidy, in testifying before the Senate Finance Committee on Monday afternoon, said that if states did not provide “adequate and affordable” coverage to those with pre-existing conditions, as the bill makes states pinky-swear to do, then the Department of Health and Human Services could always revoke their block grants. And surely Donald Trump’s HHS secretary, Tom Price, could be relied upon to provide the utmost scrutiny.
So whose votes could this new version have picked up?
The most likely pickups with these changes would have been Texas Sen. Ted Cruz and Utah Sen. Mike Lee. These two were never in the “no” camp to begin with, but Cruz did explain Sunday that they were seeking some additional changes before getting to “yes.” The relaxed regulation seemed specifically designed to collect their votes—especially since the new language would give states the ability to define the number of risk pools into which insurers may group enrollees, an omission that had prompted Lee to tank the Better Care Reconciliation Act in July.
But these revisions still didn’t pick up Cruz, and a Lee spokesman hasn’t respond to my request about his position. Cruz aides told reporters Monday that the bill still “needs to lower costs for consumers, and we are going to keep pushing for that.” Cruz wanted to insert something into the bill similar to his consumer choice amendment he advocated for over the summer. But Cassidy, in his testimony Monday afternoon, said that no more changes would be made to the bill ahead of the vote, save for fixes to technical errors.
If they couldn’t even get Cruz and Lee with these revisions, then they probably weren’t going to get any of the stickier holdouts.
As for the much-wooed Murkowski, version 2.0, even with all of its special provisions for a certain “low-density state,” wouldn’t be to her liking. Even by the authors’ own rosy estimates, Alaska would still come out with less federal funding under the block-grant regime than under Obamacare. The bill still messes with traditional Medicaid in ways that Murkowski has always had problems with and still defunds Planned Parenthood. Murkowski is also well-aware of how her image would suffer if she were “bought off” and was promising that she wouldn’t let it happen.
But Cruz’s, Lee’s, and Murkowski’s votes don’t even matter now.
McCain made clear that he opposed Graham-Cassidy on process grounds. The process hasn’t improved.
Paul is the most persuadable of the “no” camp, and he’s not persuadable. While Lee and Cruz don’t love federal spending on health care, they’ll accept it so long as it’s accompanied by enough market deregulation. Paul will not. Graham-Cassidy’s block grants, by Graham and Cassidy’s estimate, will total $1.2 trillion over a seven-year period, which is $1.2 trillion more than Paul believes the government should be spending on block grants in that seven-year period. On Monday, he held a press conference laying out his demands, which include a “significant reassessment of this trillion-dollar spending regime” as well as making all Obamacare regulations opt-in instead of opt-out. These demands cannot be met.
And then there’s Collins, who came out in opposition Monday night. The new version of Graham-Cassidy did nothing for the Maine senator. Her chief concerns with any GOP health care bill have been gutted protections for people with pre-existing conditions, protections which the new bill arguably guts further, and the per capita caps on traditional Medicaid, which the new version keeps.
Graham and Cassidy, employing some fuzzy math, had tried to make it appear as though Graham-Cassidy would provide Maine with a 43 percent (!) federal funding increase relative to current law. It’s hard to imagine that Graham and Cassidy realistically thought they could hand a sketchy piece of paper to Susan Collins and expect her to believe it. And she didn’t.
“My numbers, after a lot of work today, are very different from the numbers the sponsors used,” she told me. Specifically, her numbers showed a decrease in federal funding for her state. “Maine would end up as a net loser.”
Collins and Paul may have arrived at their positions from opposite ends of the federal spectrum. But it’s telling that they each agreed that the idea at the center of Graham-Cassidy—a formula conceived on a partisan basis to determine the allotment of massive amounts federal dollars—was, at best, a poor basis for long-term policymaking. Paul, last week, described the formula as one plucked from “thin air” to transfer money from Democratic to Republican states, a favor Democrats would return when they next took power.
Collins told me something similar Monday night. “Any group of senators who can change the formula to benefit a state can turn around and change that formula in a way that harms that state,” she said. “That is not a good way to do public policy.”