The last time anyone paid much attention to the Republican effort to repeal and replace the Affordable Care Act was when it was failing on the Senate floor in late July. That was the end of the end, we were told. Not so fast! Suddenly there appears to be a last-minute attempt — led by Lindsey Graham of South Carolina and Bill Cassidy of Louisiana — to get rid of Obamacare. How much of a chance does this last-ditch effort have? I reached out to CNN’s congressional correspondent — and resident Ohio State Buckeyes fan — Phil Mattingly to answer that question. Our conversation, conducted via email and lightly edited for flow, is below.
Cillizza: I thought repealing Obamacare was dead? No? How many lives does this effort have?
Mattingly: Man, you and everyone else, save for maybe Lindsey Graham, Bill Cassidy and a few really smart health policy reporters who stayed in tune with this effort as others (including the highest ranks of GOP leadership) rolled their eyes or were cracking the books to learn more about full expensing, mortgage interest deduction and how much each reduction of a point in the corporate rate would cost. (You know, because it’s supposed to be tax reform time.) So here’s the thing — this is definitely very alive. Does that mean they’ll get to 50? No. But the fact we’re even talking about this is quite the testament to the effort of Graham and Cassidy behind the scenes. They raised this from the dead by themselves (in fact, Sen. John Thune called Cassidy “the grave robber” yesterday because “this thing was six feet under.” Related: Thune is always great to talk to about everything.)
As to how many lives this has left, well, you’re staring straight at the ninth and final (health care is apparently a cat metaphor in my head or something.) Here’s why: Republicans are using the budget process to pass repeal and replace because it allows for a bill to pass with a simple majority. That vehicle dies on Sept. 30. So they have 11 days to get this done. If Graham-Cassidy fails, repeal is dead. Like for real this time.
Cillizza: Do we know what the preferred legislative vehicle will be (if there is one)? Is it Graham-Cassidy? Alexander-Murray? Something else? None?
Mattingly: The game right now is Graham-Cassidy. What we all thought would be the game is Alexander-Murray — that’s the bipartisan effort that was given legs after repeal/replace collapsed in July. And with good reason [given that] insurers have to sign contracts to lock in their participation in the federal marketplace by Sept. 27. They are desperately seeking certainty related to the Cost Sharing Reduction payments the Trump administration has held in limbo each month — and so are Democrats. In exchange, Alexander, the top Republican on the health committee, wants more flexibility in how states deal with Obamacare regulations. There’s a natural trade off there, though the negotiations have gone in fits and starts in recent weeks. But at the moment, as far as leaders are concerned, it’s on the backburner. Graham-Cassidy repeals and replaces Obamacare (or at least it significantly cuts back on its architecture.) That’s what they promised for seven years. So that’s the priority right now.
Cillizza: What’s different about this repeal/replace effort from the others ones that have failed? Is there something fundamentally different about what these bills propose to do?
Mattingly: There are definitely familiar elements — repealing the individual and employer mandates, ending the Medicaid expansion dollars in 2020, more regulatory flexibility for states, it puts an end to Medicaid as an open-ended entitlement and funds it on a per capita basis.
But there’s one very large difference. Unlike past efforts which maintained a less generous version of the Obamacare subsidies, this does away with that architecture all together. Instead, it keeps the majority of the Obamacare taxes [and] puts that money into block grants that would be parceled out to the states to decide what system works best for them. Yay federalism!
On its face, giving states the leeway to design their own systems is very attractive to conservatives. But the details here are super important — and as we’ve seen repeatedly, the Senate GOP conference simply isn’t ideologically aligned on health care. Medicaid expansion states will almost certainly get hit through this proposal (this would seem to be a problem for senators like Portman, Rob; Capito, Shelley Moore, Murkowski, Lisa etc.) The effective defunding of Planned Parenthood for a year is still there, which Susan Collins and Murkowski have always opposed. And no, despite the two newly scheduled hearings next week, this won’t be going through “regular order” — i.e. hearings, then committee markups, then floor action — that Sen. John McCain has made his primary issue since July. I spoke to McCain yesterday and he’s not happy with this. Doesn’t mean he’s going to be a “no,” but he said repeatedly that this needed to be sent through the committee process, time constraints or not.
Cillizza: Rand Paul appears to be a “no” to anything short of full repeal. Which means Republicans can lose 2 more votes. Who should we keep an eye on — and why?
Mattingly: The previous “no” votes are all under a microscope now. Collins has made clear she has significant problems with this and while she hasn’t come out as a firm “no,” leadership assumes she is. So, assuming Paul isn’t budging, that means McConnell will have to sweep Murkowski and McCain, who both voted “no” in July, and then hold onto everyone else. Everyone is keying on Murkowski right now — leadership and the Administration are basically going to go all out in the next 7 days to do whatever they can to get her comfortable. If she needs statistics and data? They’ll get it for her. If she wants the block grant funding formula tweaked so Alaska isn’t disproportionally hit? Consider it done. And so on. Given her previously stated concerns and priorities for repeal/replace, this will be a tough lift for them. But they’re going to give it their best shot.
The other obvious target is the Maverick himself, John McCain, whose epic 2 a.m. thumbs-down sank the effort in July. Leaders got a boost yesterday when Arizona Doug Ducey said he’s supportive of Graham-Cassidy and urged a “yes” vote. But it’s more than that with McCain, as I noted above. He gave a lengthy, and very pointed speech on the Senate floor after his cancer diagnosis about the need for bipartisanship and going through “regular order.” This is not that. The truth is nobody really knows where he’s going to end up. He’s obviously best friends with one of the bill’s authors, Graham, so there is hope inside the GOP that along with [Ducey’s] support and the hearings next week, he’ll have enough to get there. But we’ll see.
And just to add to the uncertainty, Senate Republican rank-and-file really wasn’t paying attention to this until late last week, so there are a lot of publicly stated undecideds right now. Again, the policy here is extremely important and given past concerns about Medicaid, and pre-existing conditions, and defunding Planned Parenthood, there are plenty of reasons for others to get to “no.” The question is whether momentum and seven years of campaign promises win the day.
Cillizza: Finish this sentence: “The chances any sort of repeal/replace measure passes the Senate this year is _______%.” Now, explain.
Mattingly: “¯_(?)_/¯. “
Don’t @ me.
Joking aside, I’m not trying to dodge this — people at the highest levels really don’t know. There’s no question that Republicans even getting to this point — where the effort is alive and kicking — is stunning given where they were just 10 days ago. But there is a cold reality that has never changed — they need 50 votes and don’t have a clear path to them…yet.
The question now for lawmakers is actually pretty simple: what’s more important here — doing something you promised for seven years, even if they policy doesn’t match all of your wishes and dreams or sink the last chance to repeal because it falls short. The latter has won out up until now. We’ll see if it does again.