With five legislative days remaining until the Senate GOP's reconciliation authority (allegedly) expires, Graham-Cassidy looks dead as a doornail. We know of two hard no votes (Paul and McCain), two near-certain no's (Murkowski and Collins), and a handful of additional 'no' leaners, including a new handful of Senate conservatives. Is this bill nowhere close to 50 votes?
Lee had pronounced himself "encouraged" by Graham-Cassidy developments just a short time ago, but expressed his desire to see some technical tweaks. If he and Cruz are unsatisfied with the current state of the legislation, it's deader than dead. Then again, Cruz qualified his statement with a "right now," suggesting that steps could be taken to bring the duo back into the fold. CNN reported over the weekend that in the face of setbacks and a dwindling whip count, a feverish behind-the-scenes push to get over the finish line is underway:
...The effort is still ongoing, GOP aides say -- at least for the moment. Multiple aides involved in the process say the focus on winning Alaska Sen. Lisa Murkowski's vote has continued into the weekend, with changes seen to benefit her state related to the state's funding formula in the bill and the timeline for implementation. "We're still working," said one GOP source involved in the process. For now, the source says, there are only two public "no" votes -- McCain and Kentucky Sen. Rand Paul. Even though Maine Sen. Susan Collins has said publicly she's "leaning against" the bill and has long been expected by Senate leaders to end up opposed, with only two firm "no" votes, the effort still has life, as tenuous as it may be.
Count me as exceedingly skeptical of this:
Eh, I seriously doubt it. The legislation will almost certainly get shelved or fall, leaving us...where? Lindsey Graham -- who sits on the Budget Committee and wields a powerful vote -- now appears to be demanding that the next set of reconciliation instructions (a carefully-calibrated process that makes simple majority passage of legislation possible) must include healthcare. Party leaders had earmarked this reconciliation package exclusively for tax reform:
LINDSEY GRAHAM on the FY18 budget: "We're not going to vote for a budget resolution that doesn't allow the health care debate to continue."— Sahil Kapur (@sahilkapur) September 24, 2017
Another possible complication. But let's say Graham's insistence is feasible to accommodate, and that Republicans are able to reset the clock on negotiations. Is there any cause for optimism that they'd be able to reach a consensus on any healthcare bill whatsoever? Remember, they couldn't even muster 50 yeas for "skinny repeal," which was as bare-bones as it gets. The toughest nut to crack throughout this process has been Maine's Susan Collins, a liberal Republican who has shown no stomach for repealing Obamacare, and whose steadfast support for scandal-plagued abortion giant Planned Parenthood has formed the basis for her opposition to many GOP-backed fiscal plans. She wasn't one of the first two Republican members to announce her intention to shoot down Graham-Cassidy, but she isn't being subtle about how she'd end up voting:
The truth is, it's very difficult to envision a scenario where she would end up voting for any Obamacare placement bill whatsoever. Which got me thinking: In yesterday's post, I snaked, "I'm fairly certain [Collins would] vote against her own Obamacare replacement plan at this point." Is it worth testing this proposition? In case you missed it, Collins and Bill Cassidy teamed up on an Obamacare bill in the early days of this whole saga. It's still right here on her website. It's somewhat similar to Graham-Cassidy in terms of its federalism, although its funding mechanisms are more generous. Collins' summary:
Repeals: This proposal repeals burdensome federal mandates imposed by the Affordable Care Act, such as the individual mandate, the employer mandate, the actuarial value requirements that force plans to fit into one of four categories, the age band requirements that drive up costs for young people, and the benefit mandates that often force Americans to pay for coverage they don’t need and can’t afford.
Keeps: This proposal keeps essential consumer protections, including prohibitions on annual and lifetime limits, prohibition of pre-existing condition exclusions, and prohibitions on discrimination. It also preserves guaranteed issue and guaranteed renewability and allows young adults to stay on their parents’ plan until age 26, as well as preserving coverage for mental health and substance use disorders.
State Option: The bill repeals Title I of the ACA (while retaining important consumer protections), and allows states to choose one of three options:
- Reimplementation of the ACA: Option 1 allows the State to reinstate Title I of the ACA, including its mandates and other requirements. The State can continue to receive federal premium tax credits, cost-sharing subsidies, and Medicaid dollars, to the extent that such subsidies do not exceed the contributions that would have been made under Option 2.
- Choose a New State Alternative: Option 2 allows the State to enact a new market-based system that empowers patients while still ensuring those with pre-existing conditions are protected. The State could continue to receive funding equal to 95% of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion. States can choose to receive funds in the form of per beneficiary grants or advanceable, refundable tax credits, but in both cases, funds will be deposited in a Roth Health Savings Account (HSA), meaning the money will go directly to the patient.
- Design an Alternative Solution without Federal Assistance: Option 3 would return power to the States to design and regulate insurance markets that work for their specific populations, without any federal assistance.
Conservatives will, and should, complain that this proposal maintains most of Obamacare's taxes, spending and mandates. It appears to do absolutely nothing to make Medicaid more sustainable, or to fix the Obamacare expansion's unfair imbalance toward able-bodied child's adults. It does, however, impose some minor fiscal discipline, permits additional (albeit modest) flexibility, and offer more options to states. If there is to be a last-ditch effort on replacing the existing law -- and if small, incremental improvements are better than nothing -- perhaps Mitch McConnell should use Collins-Cassidy as the framework from which an alternative would take shape. But the open question remains: If Republicans buy themselves more time, and if the rubber meets the road, would Collins back her own bill?
Key follow up: If Collins actually stood up for her own proposal, would hesitant conservatives be willing to settle for it?