It looked last week like Congress was poised to pass a plan that would fundamentally transform the country's health care industry.
The bill, introduced by U.S. Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., hadn't yet been scored by the Congressional Budget Office. It hadn't been subjected to rigorous committee hearings. And Graham told his colleagues that it would effectively serve as the last opportunity for Republicans to fulfill a key campaign promise — repealing Obamacare.
Then, on Friday afternoon, Graham's closest ally in the U.S. Senate, Sen. John McCain, R-Ariz., announced he could not support it. Graham promised to "press on" anyway.
But one more Republican defect will defeat the bill.
In broad strokes, the Graham-Cassidy plan would accomplish two things. First, it would take billions of federal dollars spent on the Affordable Care Act and redistribute that funding to all states as block grants.
Second, it would change the way the federal government pays for Medicaid.
The bill is 140 pages long. In case you're not inclined to read the proposal, here are 10 basic questions about the bill, answered:
What is a block grant?
It's a lump sum of money that the federal government would give to individual states, allowing each of them wide latitude to spend it on health care.
If the bill becomes law, each state would take about two years to design a strategy to use this money — a relatively short time frame that some experts have called ambitious, if not unrealistic.
These plans will differ from state to state. Some states may use their block grants to provide more Medicaid coverage. Others may use the money to buy private health insurance for low-income patients.
Graham has acknowledged if his bill becomes law, some states will make mistakes and others will succeed. It's unknown how much South Carolina would receive or how it would invest this money.
Does the bill benefit South Carolina?
From a financial standpoint, probably — at least initially.
The nonprofit Kaiser Family Foundation anticipates that federal health care funding for states would decrease by $160 billion between 2020 and 2026, but the amount of money South Carolina would receive would actually increase by 39 percent, from about $11.7 billion over six years to more than $16 billion. Other states stand to benefit even more. Mississippi would receive 148 percent more federal money under the proposed block grant program than it does under the existing system, the foundation said.
A separate analysis prepared by the Centers for Medicare & Medicaid Services, published by Axios on Thursday, indicates South Carolina would see a 12 percent increase in federal funds in 2020 and 126 percent more in 2026.
Generally, states that did not expand Medicaid eligibility under the Affordable Care Act, including South Carolina and Mississippi, would receive more money through 2026 than states that expanded the program.
In Arizona, where state leaders expanded Medicaid eligibility under Obamacare, federal funding would decrease by 9 percent between 2020 and 2026 if the Graham-Cassidy plan became law, according to the Kaiser Family Foundation. That may have informed McCain's decision to not support the proposal.
After 2026, all states would lose money as the law is currently written because the legislation eventually eliminates the block grant program. If Congress failed to extend the funding after 2026, South Carolina would lose an estimated $1.9 billion in 2027, according to the foundation. Other states would lose more.
Will patients with pre-existing conditions lose coverage?
The answer will probably vary from state to state. The Graham-Cassidy bill doesn't technically eliminate the Obamacare provision that requires insurance companies to cover pre-existing conditions, but it would allow states to apply for federal waivers so that insurers could bypass this rule. It is unclear, if the bill becomes law, if South Carolina would seek this waiver.
When Congress passed the Affordable Care Act in 2010, the new law required that insurance companies cover customers with pre-existing conditions, meaning they could no longer turn away or charge higher prices to patients who had health problems, such as cancer, diabetes or a history of heart disease. The law received no Republican support in Congress, but this provision has emerged as one of Obamacare's most popular reforms.
Would health insurance cost more?
Health insurance prices generally go up every year already. This holds true for employer-based health plans and plans available through the individual market. There is no evidence that the Graham-Cassidy bill would reverse this trend.
But the bill would eliminate subsidies and tax credits available to lower-income shoppers on HealthCare.gov and funnel all that money into the block grant program.
Without those discounts, people who need to buy insurance on the individual market (because they can't get a plan through work and don't qualify for a public insurance program) could end up with higher out-of-pocket costs.
In some states, lawmakers may use the block grants to make coverage more affordable. It's too early to speculate if that would happen in South Carolina.
What would happen to employer-sponsored plans?
The Affordable Care Act requires large employers — those who employ more than 50 full-time equivalents — to offer health plans to their workforce or to pay penalties. The Graham-Cassidy bill would eliminate this rule.
How much would the bill cost taxpayers?
That's still unclear. The Congressional Budget Office has not yet scored the bill. The office indicated it would publish a broad analysis of the proposal's fiscal impact early this week but that it would need more time for a detailed analysis. Experts anticipate that the bill would reduce both the federal deficit and the number of people covered by health insurance.
CBO aims to provide preliminary assessment of Graham-Cassidy bill by early next week https://t.co/tgrDGngGxk— U.S. CBO (@USCBO) September 18, 2017
Graham said during a recent press conference that his plan would cost $1.2 trillion through 2026 and would be paid for by leaving many of the Affordable Care Act's taxes in place.
Would people lose coverage?
Probably. Again, without a Congressional Budget Office score, it's hard to estimate how many people will be affected.
How would the bill impact Medicaid?
The bill would completely change how Medicaid is financed. The federal government currently contributes a percentage to each state to cover Medicaid spending. Those percentages vary from state to state, with poorer states getting a higher percentage. In South Carolina, the federal government covers about 71 percent of all Medicaid costs, more than most other states.
Under the proposed law, the federal government would set a per person cap for Medicaid spending.
Would insurance companies be required to cover maternity care or mental health treatment?
This also would vary state by state. Technically, the bill would not repeal Obamacare's "essential health benefits," which require insurance companies to cover 10 broad categories of health care, including mental health services and maternity care. But states may apply for waivers to exempt insurance companies from this mandate.
Will it pass?
This is the biggest unknown. Many groups, including the American Medical Association and AARP, have spoken out against it. Since no Democrat is expected to vote for it, only three Republicans could defeat the bill. So far, McCain and Sen. Rand Paul, R-Ky., have already said they're voting no.
If a vote is not taken by Sept. 30, Senate rules would require an even larger number of votes for it to pass.