September 19, 2017 Advocacy Alert

Senate ACA Repeal Effort Gains Steam
Urge Your Republican Senator to Reject Any Effort to Cut Health Care Services for Older Adults


With only a 12-day window left to repeal and replace the Affordable Care Act (ACA) and to cut Medicaid with only 50 votes, Senate Republicans are gaining traction behind the latest proposal to fundamentally change national health care programs. Despite an unsuccessful effort earlier this summer to repeal/replace the ACA and cap and cut Medicaid, Senators Lindsay Graham (R-SC) and Bill Cassidy (R-LA) are now trying to rush a new bill through the legislative process in only a few days. Driving this urgent effort is a ticking clock on reconciliation, which is the budgetary process employed to attempt to pass sweeping changes and cuts to health care with the support of only 50 Senators. Once the current reconciliation expires at the end of this month, Congress will need 60 votes in the Senate, which means gaining support from Democrats, to move any major health care legislation.
The specific timing and path forward for the Graham-Cassidy proposal is unclear at this point—as Senate leaders are still soliciting potential votes and support—but what is clear is that the bill would roll back ACA protections for older adults, increase health care costs for the pre-Medicare population and dramatically restructure Medicaid. A requisite analysis from the non-partisan Congressional Budget Office (CBO) is still pending, but other analyses suggest that this proposal would mean that millions of people—specifically economically and medically vulnerable older adults—could lose access to affordable ACA and Medicaid coverage.
Because this bill could see a Senate vote as soon as early next week, aging advocates MUST reach out today to their Senators and encourage them to fully reject any ACA repeal and replace measure that increases costs and reduces protections, and to oppose any Medicaid cuts that could jeopardize essential long-term care services for older adults.
Graham-Cassidy Block Grants the ACA and Restructures Medicaid

Graham-Cassidy differs significantly from previous ACA repeal/replace and Medicaid reform proposals in the House and the Senate. Put simply, Graham-Cassidy would convert the ACA to a block grant structure—or capped amount given to states from the federal government—to provide insurance premium assistance to individuals previously on the Marketplace. The federal block grant, which would end after 2026, would also be subject to annual appropriations, which means it could be cut significantly at any point by Congressional appropriators. The block grant approach leaves it up to states to figure out how they want to provide premium support to individuals and who they want to target for coverage.  
Additionally, Graham-Cassidy would eliminate the individual and employer mandate; allow states to determine which health care services they deem protected as “essential benefits”; and allow insurers to charge older beneficiaries up to five times more than younger people for health coverage (or more, should states allow that). The bill would also effectively end Medicaid expansion to low-income adults, including a disproportionate share of adults between 55 and 64, as of 2019, which is earlier than any of the previous ACA repeal/replace proposals. The proposal would roll a portion of federal funding for Medicaid expansion into the overall block grant to states and force states to use commercial insurance options to cover individuals previously on Medicaid expansion, which would likely ultimately cost states more given Medicaid’s below average per-person costs.
As with the previous repeal attempts, Graham-Cassidy goes beyond ACA and would fundamentally restructure the Medicaid program by converting it to a per-capita cap under which states would receive a set amount of Medicaid funding per beneficiary that grows more slowly each year than anticipated Medicaid costs, thereby shifting costs to states. Additionally, in order to accommodate year-over-year costs growth, Graham-Cassidy explicitly gives states flexibility to cut services—such as eliminating optional services to provide long-term services and supports (LTSS) at home and in the community. Ultimately, Graham-Cassidy appears written to drive hundreds of billions in cuts to the federal Medicaid program, which would harm older adults and people with disabilities receiving Medicaid health care and LTSS.
More details and analysis about this proposal will be available once the CBO releases its analysis, but what’s clear at this point is that Graham-Cassidy would lead to higher costs and less coverage for older adults.
Can Graham-Cassidy Really Pass?
There is a short window to push through this proposal by the end of the month. Republicans have 52 members in the Senate, and can count on Vice President Mike Pence to break any 50-50 ties. Therefore, Republicans can only afford to lose two votes under the current reconciliation process, which leaves little room for Republican defection.
According to recent reports, Senators Graham and Cassidy have commitments from 49 of their colleagues—including a potential yes from Senator John McCain (R-AZ), who was the final dissenting vote earlier this summer. Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK) have not yet announced their positions, but one or both could support. Senator Rand Paul (R-KY) has already said he’s a “no” vote.
Should this measure pass the Senate in the coming days, the House would have to take it up and pass it without amendment by September 30. There would be no time for a conference committee, and no time to offer any changes.
Advocacy Needed NOW!

If this bill moves in the next two weeks, it would be a blatant defection from the “regular, bipartisan” order that lawmakers on both sides of the aisle pledged following previous Senate action on a bill to repeal and replace the ACA. Passing Graham-Cassidy would continue to advance a deeply flawed process that has consistently threated health care coverage for older adults in both the Marketplace and on Medicaid. n4a remains opposed to both the process and the proposals that Congress is considering, and it is essential that local advocates continue to weigh in to encourage your Senators to vote against any bill that continues to advance these provisions.
Instead, we encourage lawmakers to stop this mad-dash process and continue a bipartisan, transparent and inclusive process, which is already under way, that seriously considerers the challenges inherent in the ACA and also leaves unrelated Medicaid cuts off the table.
Local advocacy is key to stopping these devastating proposals from moving forward. Senators—especially from key states AK, ME, OH, WV, CO, KS and MT—must KEEP hearing about how harmful these measures could be to their older constituents.
Aging advocates must weigh in now to tell your Senators to reject ANY proposal that reduces coverage, raises costs and cuts Medicaid.
Please make a quick call, send an email or fax, and encourage your agency’s stakeholders to do the same to keep up the drumbeat about the health care reform proposals that are being considered. You can find contact information for your Senators’ state and Washington, DC offices at
The message now to Senators is simple:

I urge you to stop any attempt, including Graham-Cassidy, to repeal and replace ACA that jeopardizes coverage and increases costs for older adults. I also urge you to reject cuts and caps to Medicaid. Please oppose any proposal during this debate that keeps this process moving without broad, bipartisan input.
Instead, any changes to health care must be done through an open, bipartisan and transparent process that protects older adults and preserves critical Medicaid funding.

We urge you to continue using n4a #SaveMedicaid ( campaign page, for advocacy tools and resources to engage your grassroots and local partners! We also encourage you to share n4a’s Policy Brief, “What Would ACA Repeal Mean for Older Adults, Caregivers and the Aging Network?” This Policy Brief includes key questions and considerations that lawmakers must address in any future attempts to improve the ACA.
Again, advocacy NOW week is critical. Congress has only until September 30 to pass a partisan ACA repeal and replace bill that will also gut Medicaid. The time is short to STOP devastating cuts to health care and long-term services and supports for older adults.


If you have questions or concerns about this Advocacy Alert or n4a’s policy positions, please contact Autumn Campbell at and Amy Gotwals at