As you may remember, congressional Republicans attempted to pass legislation earlier this summer that would have repealed and replaced the Affordable Care Act, AKA Obamacare. The bills would have profoundly changed health insurance across the country, and the final measure ultimately failed when Sen. John McCain (R-AZ) joined Sens. Lisa Murkowski (R-AK) and Susan Collins (R-ME) in voting “no.”

That wasn’t the end, though. Congress is back with new efforts to overhaul health care, and interest groups have wasted no time in staking out positions. This time there are three separate proposals to change the state of American health care, with some more concrete than others.

Here’s what each of the proposals do – and who’s behind them.

Repeal-and-replace (remixed): the Graham-Cassidy Bill

The first proposal, brought forth by Sens. Bill Cassidy (R-LA), Lindsey Graham (R-SC), and Dean Heller (R-NV) is a new twist on earlier repeal-and-replace efforts.

The Graham-Cassidy bill would recenter the health insurance system on the states. As the Washington Post’s in-depth rundown explains, under the legislation, states would receive a block grant of the money the federal government currently spends on Medicaid and subsidies to make insurance more affordable for lower-income people. Each state would then be able to determine how and where to spend the health care money.

Some of Obamacare’s other elements would end up on the chopping block. Individuals would no longer be required to have coverage, and large employers would no longer have to provide affordable insurance to their employees. The Medicaid expansion would end in 2020. People under the age of 26, however, would continue to be able to sign onto their parents’ coverage.

After declining over the course of the next decade, the block grant given to states would zero out completely in 2027. Bans on lifetime caps on coverage would remain, but states would be allowed to redefine what constitutes an “essential health benefit.”

Who’s behind it?

Thanks to Senate rules, Graham, Cassidy, and Heller are racing against time. In order to pass the measure with a bare, fifty-plus-one vote majority in the Senate through a process known as reconciliation, the bill would need to pass by September 30.

Whether that will happen is tough to say. No Democrats are expected to back the measure and it’s not totally clear which Republicans will get on board. Murkowski has not taken a public position, Collins has expressed reservations, and a senator who voted for the earlier repeal-and-replace measure, Ohio’s Rob Portman, has not yet come out in favor. To make matters worse for the measure’s sponsors, McCain announced on Friday that he “cannot in good conscience vote for Graham-Cassidy.” And another past yes, Sen. Rand Paul (R-KY), actually came out in opposition to the bill, tweeting “No conservative [sic] should vote for a rebranded trillion dollar spending program just because it adds some block grants.”

Assuming Portman falls in line on this effort, the sponsors would need yes votes from both Collins and Murkowski to see it passed.

One of the things that makes Graham-Cassidy so interesting is that it has no clear constituency. With its diminishing subsidies and the individual and employer mandates scrapped, the bill makes no friends of the health insurance industry, which stands to lose a significant portion of its customer base. Further, 16 health care groups, including the American Lung Association, National Health Council and the American Diabetes Association, signed onto a letter opposing the measure. And here’s a list of comments on the bill from major health industry groups, including insurers.

Republicans have campaigned on repealing Obamacare for the better part of a decade, but even conservative groups have spoken out against the Graham-Cassidy approach because, well, it doesn’t actually repeal the Affordable Care Act – remember Rand Paul’s tweet. At the state level, 15 GOP governors pledged their support for the measure, though four others joined a letter calling for bipartisan efforts to reform health insurance.

Sanders gets Dems interested in Medicare for All

The debate over the future of health care has changed on the left, too. That’s by and large thanks to Sen. Bernie Sanders (I-VT), whose presidential run last year energized arguments for a broader government role in the nation’s health insurance system.

This year, Sanders reintroduced his Medicare for All bill, a measure that would implement single-payer health insurance. The measure would introduce a health insurance system in which the federal government would be the “single payer”, negotiating directly with hospitals, drugmakers and other providers. Instead of buying health insurance from a private insurer, Americans would essentially pay for insurance through their taxes, as is the case in several other countries, including France and the United Kingdom.

The government already administers health insurance through a number of programs, including Medicare and Medicaid. Proponents argue the shift would save money, especially for lower-income earners, since the government would negotiate the price of treatments and drugs, reducing administrative costs and increasing efficiency.

Others disagree. Since costs would shift from private insurers to the government, opponents contend, the increased public expenditures would require higher taxes. And without out-of-pocket expenses, more Americans would feel the incentive to use health services, raising overall costs. In total, the Urban Institute estimated the switch could cost the federal government roughly $32 trillion over the course of ten years as it absorbs state and local spending.

Who’s behind it?

Republicans control both houses of Congress and the presidency, which makes it unlikely that the measure will become law in the near future. Support for the bill is growing among Democrats, but special interest pressure could be playing a role in who’s signing on.

Naturally, private insurers are opposed to a bill that would functionally eliminate them. What’s most interesting, however, is the interplay between insurance industry money and support for the measure.

So far, 16 Democratic senators had signed onto the Medicare for All bill. As Maplight found, however, industry contributions to Democrats who have not sponsored the legislation almost doubles the average amount given to supporters. Since 2010, health insurance employees and PACs have contributed an average $23,600 to sponsors and $55,500 to non-sponsors.

The one that got away: Bipartisan compromises

The third proposal was slotted squarely in the middle: not a repeal or a replacement, but a fix of the Affordable Care Act. Earlier this summer, Sen. Lamar Alexander (R-TN) and Sen. Patty Murray (D-WA) proposed the idea of finding a bipartisan solution on health care. The efforts ultimately fell apart last Tuesday after the parties failed to find workable common ground.

The measure would have left Obamacare in place and maintained subsidies that allow lower-income people to buy health insurance – two things that appealed to congressional Democrats. In return, states could have had more flexibility in administering the program’s regulations, a move that would have addressed some of the GOP’s concerns tackled in the Graham-Cassidy proposal.

And the compromise effort was as much about substance as it was about procedure. Much of the ire surrounding both the past Obamacare repeal effort and the current Graham-Cassidy measure has centered on the expedited path the bills have taken through the legislature. After casting a vote to kill the so-called skinny repeal of the Affordable Care Act, Sen. McCain called for a “return to the correct way of legislating,” in which Congress would “send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people.”

Who was behind it?

The Alexander-Murray efforts, which McCain praised in another statement, would have slowed the breakneck pace, having aimed for a bill to be taken through committee hearings and crafted to win bipartisan support. That was as much idealistic as it was pragmatic, since after September 30th, a health care bill would need 60 votes in the Senate to pass, thereby requiring both Republicans and Democrats to get on board.

The compromise approach made the efforts popular with health industries writ large, which tend to prefer order and stability. In the face of Obamacare’s uncertain future, insurers raised premiums and noted that ending cost-sharing subsidies, as President Trump had threatened to do, could push prices even higher.

Before it’s demise, the Alexander-Murray effort was designed to stabilize insurance markets through standard legislative order. That was a move that won plaudits from health providers like the American Lung Association and influential consumer advocates. One such group, the AARP, also praised the bipartisan efforts and pressed members of Congress “to focus on commonsense solutions to stabilize the Affordable Care Act (ACA) insurance marketplace, increase enrollment and competition, and lower costs for consumers.”

Special interests on the horizon

It’s fair to say that the fight over American healthcare isn’t quiet and it isn’t over. While it may be too early to get a full picture of the special interest landscape, industry groups have been involved since the first repeal-and-replace effort, a reality that birthed the great Lisa Murkowski quote: “I am not a reporter, and I am not a lobbyist, so I’ve seen nothing.”

And the health sector – a broad group of hospital, pharmaceutical, and HMO industries – is no stranger to lobbying. Since the beginning of 2017, companies in the field have spent $284 million to influence the federal government. Going back to 2010, the year the Affordable Care Act was signed into law, the sector has spent $3.7 billion on federal lobbying.

With all the talk of overhauling the nation’s health care systems, 2017 has been a busy year for insurers in Washington. Major health insurance companies spent $6.2 million lobbying in the first three months of this year alone, primarily pushing lawmakers to maintain the individual mandate and cost-sharing subsidies discussed above. One such insurer, the Blue Cross Blue Shield Association – which has expressed “significant concerns” about Graham-Cassidy – spent more than $2.5 million in the first quarter to influence the government.

And interest groups will continue to exert pressure on lawmakers considering the range of health care options. As efforts move forward, the lists of supporters and opponents to each plan will firm up even further. Regardless of the final outcome, it’s a pretty safe bet that the people, groups and companies on all sides will splash the cash to make their voices heard.

About Jack Noland
Jack Noland has written about and reported on money in politics since 2015. He joins Represent.Us after earning a B.A. at George Washington University, where he studied political science and creative writing.
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