A selfie of Iowa Sens. Joni Ernst and Chuck Grassley before the 2016 State of Union Address, tweeted by Grassley.
The latest Senate bill to repeal the Affordable Care Act (ACA) — the Graham-Cassidy bill — would remove protections for people with preexisting conditions, create new restrictions on women’s health care and reduce subsidies for individuals buying their own insurance. It would also cut federal health care spending in Iowa by more than half a billion dollars, according to an analysis by the Center for Budget and Public Priorities (CBPP).
Neither of Iowa’s U.S. Senators has taken a public position on the bill, even though the Senate will have to vote on the bill before the end of the month. The bill must be voted by then, if the Republican majority is going to pass it using the budget reconciliation process, which will prevent the bill from being filibustered and allow it to be approved with only 51 votes.
So far, the only hearing scheduled for the bill is by the Senate Homeland Security and Governmental Affairs Committee, a committee that typically has no role in creating health care policy. The committee is chaired by Sen. Ron Johnson of Wisconsin, one of the co-sponsors of Graham-Cassidy.
In contrast to the current rush, the Senate held 44 committee meetings and public hearings on the ACA. The process — from the time the House of Representatives sent the bill to the Senate until it was signed into law — took eight months.
The Congressional Budget Office has announced there will be no full analysis of the bill before the Republicans’ deadline, because it won’t be able “to provide point estimates of the effects on the deficit, health insurance coverage, or premiums for at least several weeks.”
Certain aspects of the bill are clear, however. It would create a waiver system, under which states could opt out of certain ACA protections. For example states could allow insurance companies to charge people with preexisting conditions more, and the bill does not set a cap for how much more. Waivers would also make it possible for insurance companies to increase premiums on people who develop illnesses that are expensive to treat, such as cancer, while insured.
States could also waive requirements for maternity care under Graham-Cassidy. The Century Fund estimates that as many as 13 million women could lose access to maternal care programs. The bill’s provision that ends the expansion of Medicaid included in the ACA would have a profound impact in this area. Currently, more than half of all births in the United States are covered by Medicaid.
Graham-Cassidy also goes further than previous repeal bills to restrict access to abortion services. The use of federal funds for abortion services has been restricted since 1977, but under Graham-Cassidy no insurance policy that receives any federal funds, either because the person buying it receives a subsidy or because the insurer participates in the federal reinsurance program created by the ACA, can cover abortion services. The only exceptions would be for cases of rape or incest, or if the life of the mother is in danger.
But the feature that most clearly distinguishes Graham-Cassidy from previous repeal bills is how it transforms Medicaid. According to the CBPP, the bill would eliminate “the ACA’s marketplace subsidies and enhanced matching rate for the Medicaid expansion and replace them with an inadequate block grant [beginning in 2020]. Block grant funding would be well below current law federal funding for coverage, would not adjust based on need, would disappear altogether after 2026, and could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance.”
The CBPP estimates this would lead to $239 billion less in overall federal health care spending between 2020 and 2026, and Iowa would see a reduction of $515 million in federal funds during those years compared to current spending projections. After 2026, the CBPP writes, Graham-Cassidy “would be virtually identical to a repeal-without-replace bill” with one major exception, because the bill also fundamentally changes how the federal government pays for Medicaid.
Since the creation of Medicaid, it has been funded by both the federal and state governments and the level of funding has been determined by the needs of the people enrolled in it. Graham-Cassidy would set the federal government’s contribution according to the number of people enrolled, not their cost of the treatment. The Kaiser Family Foundation notes that states with certain demographic challenges — including states like Iowa that have disproportionately older populations, who typically have greater health care costs — “may have the hardest time responding to federal caps on Medicaid spending.”
Still, neither of Iowa’s senators has announced a position on Graham-Cassidy. Sen. Chuck Grassley has previously said that he supported the approach taken in Graham-Cassidy, but his office did not respond to questions from Little Village regarding the senator’s position on the bill.
Sen. Ernst’s office did respond to a Little Village email containing six specific questions. Instead of answering the questions about Graham-Cassidy and the rushed attempt to pass it, the unsigned email simply stated: “In response to your request, Senator Ernst is still going through and evaluating how this would impact Iowa.”
Grassley and Ernst voted in favor of both previous ACA repeal bills offered by Senate Republicans this year.