As of this writing, just about the only concrete information Americans have about the Graham-Cassidy proposal is the text of the bill itself. And legislators appear not to have grasped much beyond the basic structure of the law—which would replace the Affordable Care Act’s Medicaid expansion and premium tax credits with a block grant to states, and would establish per capita caps for base Medicaid. On Tuesday, while being interviewed by Vox about the bill, nine GOP senators barely, if at all, talked specifics. The lawmakers could point out the broad strokes of block grants and Obamacare repeal, but didn’t go much further than that. Their sentiments could be largely summed up by Texas Senator Ted Cruz, who said that “the heart of the legislation takes the policymaking role of Washington and sends it to the states.”
But the mechanisms of how that would work—and the economic and coverage effects those mechanisms would have—are still very much unknown. While the few independent analyses that exist (from Avalere, Manatt, and the Kaiser Family Foundation) agree on a few matters—that overall federal funding for coverage would be slashed, that the bill would redistribute funds from Medicaid-expansion states to non-expansion states, and that it would constrict Medicaid funding over time—there’s still a divergence on specific estimates.
That’s because the formula Graham-Cassidy would use to allocate Medicaid expansion and exchange funding to states is complex, and not completely outlined in the text itself. It would involve different inputs from year to year about state choices, cost-sharing-reduction calculations, inflationary factors, total federal expenditures, population-risk adjustment, the actuarial value of existing programs, and a bevy of other demographic factors and year-to-year economic factors. Additionally, the biggest unknown is what happens after 2026, when the block grant ends. Will states have access to funding at all? If the funding does suddenly end, are there guardrails to keep state-health infrastructures from collapsing? What pieces of the current law would apply or not apply in that scenario?
With all these question marks, it’s impossible to come up with a firm number of people Graham-Cassidy would cover, which is the key output for any health policy. Given the funding decrease and the already-modeled effects of ending the individual mandate and capping base Medicaid, it seems a safe bet to assume the bill will increase the number of uninsured by north of 12 million people in the next decade above current projections. And given that, if the block grants are not renewed after 2026, the outcome would be identical to straight Obamacare repeal—worst-case models assume an upper bound of 32 million or more additional uninsured people.
It seems uncertainty is the desired legislative state for Senate Majority Leader Mitch McConnell and the GOP. When faced with news that, with just a week for turnaround, the Congressional Budget Office’s methodical analyses—which would involve modeling and gathering as much information as possible on unknowns and assumptions—would only be able to provide a rough assessment of Graham-Cassidy, Cruz echoed longtime Republican criticism of the CBO. The senator called the independent scoring agency “ridiculously slow, unreliable, and based on policy assumptions that are demonstrably false.” But unlike during the last round of repeal with the BCRA—when Republicans relied on a quickly spun-up and fuzzy score from the Department of Health and Human Services to justify not waiting for the CBO—now GOP leadership seems content with having no numbers at all.