All eyes are on Alaska Republican Sen. Lisa Murkowski as she decides how to vote next week on her party's Graham-Cassidy bill, which would replace the Affordable Care Act with a system of temporary block grants to the states.
There are reports that Senate GOP leaders are crafting a version of the bill that would be more attractive to Murkowski in terms of funding for Alaska, which has high medical and insurance costs and expanded Medicaid under the ACA. The new provisions reportedly would give Alaska (along with Hawaii for some unknown reason), preferential treatment on federal funding for premium subsidies, Medicaid per capita caps and payments for traditional Medicare.
Murkowski was one of three GOP senators, along with Maine's Susan Collins and Arizona's John McCain, who voted no on the last repeal bill in July, narrowly killing it. Her vote is seen as pivotal for Senate Majority Leader Mitch McConnell to get the 50 votes he needs to pass the bill before the Sept. 30 expiration of authority to do so with a simple majority.
The original Graham-Cassidy bill, unveiled only last week, already included preferential treatment for Alaska and four other low-density states. It would delay cuts for those states under the bill's per capita cap formula for federal Medicaid payments. Even so, Alaska's independent governor, Bill Walker, joined a bipartisan group of 10 governors who oppose the legislation.
On Thursday, the bipartisan National Association of Medicaid Directors joined the opposition, arguing that most states would not be able to design and implement their own coverage systems within the bill's two-year time frame.
"Any effort of this magnitude needs thorough discussion, examination and analysis, and should not be rushed through without proper deliberation," the association said.
Meanwhile, there is heated debate about how Senate parliamentarian Elizabeth MacDonough's expected rulings on the bill next week will affect its provisions and political prospects.
Experts differ on whether MacDonough will find that the provisions allowing states to waive ACA insurance market rules such as community rating and essential health benefits will comply with Senate budget reconciliation rules requiring all provisions to be budget-related. There also are doubts about whether the prohibition on abortion coverage and funding for Planned Parenthood will survive the parliamentarian's vetting.
America's Health Insurance Plans announced its opposition to the bill Wednesday, rejecting the waiver of insurance market rules. It argued that "reforms must guarantee access to coverage for all Americans, including those with pre-existing conditions. No one should be denied or priced out of affordable coverage because of their health status."
MacDonough struck down the waiver of the ACA's insurance rules in previous Senate repeal bills. But this version comes packaged inside a new state block grant structure, which could make it budget-related. Some experts think that could enable it to pass the procedural test.
The waiver of insurance rules is "the million-dollar question," said Sarah Binder, an expert on congressional procedure at George Washington University. "I don't have a sense of where the parliamentarian will end up."
If the insurance waivers are stripped out, that would greatly reduce the state flexibility that's key to congressional Republicans and some GOP governors. Then all the bill would offer states—including those such as Alaska, Arizona, Colorado, Kansas, Ohio and West Virginia represented by wavering Republican senators—is a lot less federal funding.
"Flexibility without the capacity to implement isn't very helpful," said Becky Hultberg, CEO of the Alaska State Hospital and Nursing Home Association, which is pressing Murkowski to vote no on the bill.
There's also speculation about whether Senate Republicans will try to extend the Sept. 30 budget reconciliation deadline to pass their repeal bill by a simple majority if they feel they are close and need a little more time. Parliamentarian MacDonough had ruled the budget reconciliation instructions expire on that date.
Binder said it's technically possible to ignore the parliamentarian's ruling and ignore the deadline. "But politically, that seems unlikely to me," she said. "The current Senate GOP does not seem eager to start ignoring the advice of the parliamentarian. That's not typically how Anglo-American parliaments work."
Murkowski reportedly has been talking to federal and state officials about the bill's financial impact on her state. But two independent analyses of the bill this week show Alaska receiving about $1 billion less in federal funding from 2020 to 2026 than it would get under the ACA. Avalere Health projected Alaska would get $14 billion less over the longer term, from 2020 to 2036.
The bill, however, would give HHS Secretary Tom Price a lot of discretion to adjust funding to states like Alaska. Murkowski may be seeking assurances that Price would smile on her state.
"There's a lot of room for the secretary to move money around," said Edwin Park, vice president for health policy at the liberal Center on Budget and Policy Priorities. "The whole idea of block grants is predictability, but there's a lot of unpredictability in this bill."
If Murkowski is swayed by what's being called the "Alaska Purchase," that would run counter to a strong statement she made in June, when she frowned on a special deal for her state to win her support for a repeal bill.
"This is like a really big deal to get this right for the country," Murkowski told reporters then. "Let's just say that they do something that's so Alaska-specific just to quote, 'get me.' Then you have a nationwide system that doesn't work. That then comes crashing down, and Alaska's not able to kind of keep it together on its own."
