What’s in the new version of Graham-Cassidy ACA repeal bill

Multiple risk pools and extra money aimed at states represented by Republican swing votes are among the changes made in a new version of the Graham-Cassidy bill to repeal the Affordable Care Act (ACA) to be released five days before a deadline to pass it with a simple majority in the U.S. Senate.

The first edition of the legislation, named after its main architects, Sens. Lindsey Graham, R-South Carolina, and Bill Cassidy, MD, R-Louisiana, was criticized for maintaining a provision which had been controversial in past ACA repeal bills. States would be able to allow insurers to charge customers more based on health status, which could potentially price people with pre-existing conditions out of the market, even though the ACA’s standard that they not be denied coverage would be maintained.

The new version keeps that provision and adds a new wrinkle that could further impact those patients: multiple risk pools. Instead of the ACA’s single risk pool, states could create multiple risk pools with the aim of driving down premiums for the healthier customers—a change that insurance companies had opposed in an earlier repeal bill.

“The revised Graham-Cassidy bill is in effect federal deregulation of the insurance market,” tweeted Larry Levitt, senior vice president of the Kaiser Family Foundation.

Multiple risk pools is one of several new options for states looking to waive ACA regulations included in the new bill. States would be able to alter or eliminate requirements on age rating, actuarial value, essential health benefits, cost-sharing and preventive services. Additionally, states would no longer have to submit formal waivers to HHS for approval to make these changes, just “describe” their plans.

After gaining some unexpected momentum, the bill was dealt a heavy blow on Sept. 22 when Sen. John McCain, R-Arizona, said he would vote against it, joining Sen. Rand Paul, R-Kentucky in opposition. One more “no” from a Republican would guarantee the bill’s failure in the Senate, and Sens. Susan Collins, R-Maine, and Lisa Murkowski, R-Alaska, who voted against the last attempts at ACA repeal, are officially undecided.

The new version of Graham-Cassidy would direct more funding to the states of those four senators. Several new provisions specifically benefit Alaska, such as allowing Alaska Natives to remain eligible for Medicaid even after the expansion is rolled back in 2020 and offering a 25 percent increase in federal matching funds to it as the state with the highest poverty guideline.

These changes to appeal to the moderate swing votes may drive away more conservative senators, however. On Sunday, Sen. Ted Cruz, R-Texas, said at the Texas Tribune festival that “they don’t have my vote” and said Sen. Mike Lee, R-Utah, may also be a “no.”

For the healthcare industry, the changes wouldn’t appear to address their concerns that the legislation will lead to tens of millions of people no longer being insured and destabilize the individual market. Six industry—the American Medical Association, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, America’s Health Insurance Plans and the Blue Cross Blue Shield Association—spelled out their opposition in a rare joint letter to Senate leaders.

“While we sometimes disagree on important issues in health care, we are in total agreement that Americans deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all,” the groups wrote.