Postgaming Sunday’s Graham-Cassidy Action

Another day, another draft of Graham-Cassidy. And yet another slew of special deals for Alaska, which I have criticized as unconstitutional elsewhere. Congressional Republicans must pass their recent version of Obamacare repeal by September 30 to avoid the filibuster rules that are usually applicable, and which would require a 60 vote threshold. Until then, they need only 50 of the Senate’s 52 GOP Senators to eke out a victory. John McCain has said he won’t vote for the bill; Susan Collins has said she is leaning against it. Rand Paul, after signalling early disapproval of the bill because it did not go far enough, is now negotiating with the bill’s authors to roll back even more patient protective regulations.
If Paul shifts, eyes once more will turn to Lisa Murkowski. In anticipation of this, news outlets are once more reporting sweeteners to Alaska that characterized earlier versions of the bill. The reporting is somewhat vague and sometimes inaccurate, so I thought a deper dive would be helpful.
I must caveat all of this by noting that this analysis is based on a quick read of a bill that was released just today—I welcome any corrections or additions.

* Five percent of the funds appropriated for a particular “short term assistance plan” will be distributed to low density states (with less than 30 people a square mile). (Bill, p. 7). This by itself isn’t horribly disproportionate at the moment—in 2015, these states had 3.8% of the population. But over time, as the population in some of these states keeps dipping, it will grown more disproportionate. NBC misreports, however, that 5% of all federal funds will be going to these states, which does not appear to be the case. But Alaska is one of the 9 states that benefits from this slight bump.
* It reintroduces (p. 22) a provision that was floated earlier, that would give a bump in funding to low density states whose healthcare costs are more than 20% of the population. This benefits only North Dakota and Alaska. The bump is proportional to how much their costs exceed the national average, so Alaska at 38%, benefits more than North Dakota, at 22%. As I mentioned in my earlier post, the argument that Alaska needs this special treatment is nonsensical. The agency is given the power to adjust the funding to take into account healthcare costs, and there are other reasons for high healthcare costs than low density. 
* For states that obtained 1332 waivers under the ACA (exactly two states as far as I can see—Alaska, and Hawaii) an additional 500 million dollars is made available. (p. 44).
* It imposes penalties on states whose costs with respect to certain beneficiary groups exceed that of the national average by more than 25%. (p. 81). It exempts from this low density states. It is likely that this benefits only Alaska, and maybe North Dakota, if it benefits anyone at all. 
* The states with separate poverty guidelines as of 2017 get additional federal match funding (FMAP). (p. 141-43). This benefits two states—Alaska and Hawaii, the only two states in that category. Alaska will get a bump of 25% of the average spending of the other states. Hawaii will get 15%.
* It keeps in place certain funding for Native Americans (p. 138). This benefits states with high Native American populations. At 16.5%, Alaska’s share of Native Americans (Alaska Natives) dwarfs that of other states. New Mexico and Oklahoma follow, with 9.5% and 8% respectively, with a few other “high percentage” states hovering at around 5%.
One interesting tidbit. Vox reported that states that recently expanded Medicaid under the ACA would also get additional money. I expected that this would also benefit Alaska, as Alaska expanded Medicaid only in 2015, as did a couple of other states—Indiana and Montana. But as it turns out, a state would have had to have expanded sometime in 2017 to get this perk. (p. 42).  (NB—CNN reports a 2015 cut off.  It’s either using a different version of the bill or got this wrong).

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