Republicans hammered Democrats seven and a-half years ago for larding Obamacare with state-specific payoffs and sweeteners to secure the last few votes for passage. Who can forget the “Cornhusker Kickback,” which funneled $45 million to Nebraska to nail the support of former Sen. Ben Nelson?
But the revised Senate Obamacare repeal bill shows Republicans engaged in the same pattern of horse trading as they try to win 50 ayes to advance an unpopular bill.
Leaders are likely to cook up even more deals to entice uncommitted senators. As conservative health policy expert Chris Jacobs points out at The Federalist, Majority Leader Mitch McConnell still has about $200 billion that he can spend on holdouts without breaking Senate budget rules he’s using to try to pass the legislation. The Trump administration is pitching a proposal to Nevada as a way to bring Republican Gov. Brian Sandoval and Sen. Dean Heller on board that aims to move Medicaid expansion enrollees into the private insurance market where they could use subsidies to help pay for premiums.
Here’s a rundown of some of the ways the latest bill seeks to win over members of the GOP caucus:
Alaska — The most blatant attempted buyoff is aimed at Alaska’s Lisa Murkowski, who has been decidedly unenthusiastic about potential coverage losses in the state. In what’s been dubbed the "Polar Payoff," the revised legislation stipulates that any state with premiums that are at least 75 percent higher than the national average must receive at least 1 percent of state stability funding. There’s only one state that meets that threshold: Alaska. With $182 billion designated for stabilization efforts in the revised bill, that translates to at least $1.82 billion for Alaska. While that’s a big pile of cash, Aviva Aron-Dine at the Center on Budget and Policy Priorities points out that the state expects to lose $3.1 billion in Medicaid funding between 2020 and 2026 under the Senate bill.
Alaska would also benefit from a provision that would provide a 100 percent federal match for spending on medical assistance by any provider to American Indians enrolled in Medicaid. That’s expected to cover Native Alaskans, and about 15 percent of the state’s population are American Indians or Alaska Natives. The match currently applies only to services received through an Indian Health Services or tribal facility.
Late Medicaid expansion states — The Senate bill makes a couple of arcane changes to the formula for establishing future per capita Medicaid payments that will benefit Louisiana, Alaska and Montana. That funding formula has been a major concern of Sen. Bill Cassidy, who is viewed as a potential holdout. Initially, the caps would have been based on eight consecutive fiscal quarters selected by the state. That’s a problem for Louisiana because it didn’t expand Medicaid until last year, adding more than 400,000 individuals to the rolls. That means it doesn’t have eight quarters of financial data that reflect its current Medicaid population. The revised bill explicitly allows late-expanding states to use as few as four quarters of data for their funding baseline.
The original bill also prohibited states that didn’t have Medicaid expansion in place in 2016 from using the expanded population for calculating its per capita base. But under the revised bill, the deadline is July 1, 2016, which happens to be when Louisiana’s expansion took effect. Two other states — Alaska and Montana — would also potentially benefit from these changes.
“Buffalo Bribe” — This provision was originally stuck in the House bill at the behest of Rep. Chris Collins of New York, who has long been angered by the way his state forces county governments to contribute to its Medicaid program. It would penalize states that do this by reducing their federal payments by whatever amount local governments are required to pay. The provision resurfaced in the Senate bill, but it’s not clear at whose behest. However, as New York Magazine’s Ed Kilgore pointed out, adhering to deals that were cut in the House could make it easier for the lower chamber to directly take up and clear whatever the Senate passes.
Florida — The bill would exempt some spending from the Medicaid per capita cap in the event of a public health emergency. That was a priority for Sen. Marco Rubio of Florida, whose home state has been fighting the Zika virus outbreak. The bill also makes a change in the funding formula for hospitals that see a large number of poor and uninsured patients, using the number of uninsured instead of the number of Medicaid enrollees to calculate payments. That will particularly benefit states like Florida that didn’t expand Medicaid and have higher uninsured rates.
Arkansas — The revised bill allows states that opt for a Medicaid block grant to include their expansion population in that funding. That’s a change that Arkansas Gov. Asa Hutchinson has lobbied to be included. Although it’s not clear if it would result in more money for the state, it would at the least provide additional flexibility on how those dollars are spent.