A last-minute attempt to replace the Affordable Care Act in the U.S. Senate has not yet won the endorsement of Iowa's two Republican senators, but the plan could be headed for a vote.
A new Republican bill, championed by Sen. Bill Cassidy, R-La., and Lindsey Graham, R-S.C., has resurrected the battle over health care in Washington, D.C., just weeks before the Nov. 1 enrollment period for Affordable Care Act markets is scheduled to open.
The legislation would revoke several parts of Obamacare, such as the one requiring individuals to buy insurance. It also would take funding from the Affordable Care Act's Medicaid expansion, premium tax credits and cost-sharing reduction payments and put them into a block grant to be sent to states for health care spending.
Previous GOP plans brought to a vote this year have not included this block grant approach.
The plan's authors say the proposal will give states flexibility and, additionally, would redistribute Medicaid expansion money from some big states they say get too much, including California, Massachusetts and New York. Other states would benefit, including those that did not expand Medicaid eligibility under the Affordable Care Act, also known as Obamacare.
Critics say that, like other GOP proposals, the plan would mean millions fewer Americans would be insured. Expanded Medicaid eligibility would end on Dec. 31, 2019, in the new proposal. They also say states such as Iowa and Illinois would lose money relative to what they would receive under the Affordable Care Act.
So far, Iowa's two senators, Joni Ernst and Chuck Grassley, haven't said how they would vote.
"Senator Ernst is still going through and evaluating how this would impact Iowa," Leigh Claffey, a spokperson said Monday in an email.
In a statement, Grassley said Monday he, too, is still looking at the bill. But he said he likes that it "returns power to states and individuals," phases in changes and allows for alterations in the future.
"We need alternatives to Obamacare, which hasn't worked," Grassley said.
Ernst and Grassley have previously voted for Republican-written Obamacare replacement plans. Those proposals failed to get 50 votes in the Senate. In part, moderate Republicans refused to support them in the face of Congressional Budget Office estimates that millions fewer Americans would be insured under those proposals.
This latest attempt resembles those earlier plans in some ways. One of the most fundamental similarities is it that would change how traditional Medicaid is funded, switching it to a system that pays states on a per-capita basis. Currently, the program is open-ended, with the government funding approved expenses for those who qualify.
The nonpartisan Congressional Budget Office hasn't weighed in on the new plan yet. However, the Center on Budget and Policy Priorities, which has been critical of GOP plans, says taking the block grant and per capita provisions together, Iowa would lose $525 million in 2026. Illinois would lose $1.4 billion in 2026, it said. The organization also said the bill would disrupt individual markets.
Iowa Gov. Kim Reynolds didn't pass judgment on the bill. But in a statement, her spokesperson, Brenna Smith, pointed favorably to the 1990s-era block grant system that replaced the existing federal welfare program, which she said is a model that works.
"If Congress pursues block grants, the governor believes they need to adequately fund them and provide maximum flexibility and control for states to sustain their Medicaid programs," Smith said.
Republicans are seeking to get a bill to the Senate floor before the end of the month, enabling legislation to pass with just a majority. After that, Senate rules will require 60 votes.
Since the major provisions of the Affordable Care Act kicked in, Iowa's rate of uninsured has been reduced by about half. However, for people who do not get subsidies or Medicaid, premiums have increased significantly. Meanwhile, just one company, Medica, has said it would be willing to sell policies in Iowa's marketplace next year and only with markedly higher premiums from this year.