Recipient: U.S. Senate
On behalf of The Leadership Conference on Civil and Human Rights, the National Health Law Program, the National Partnership for Women & Families, and the undersigned 234 organizations, we urge you to oppose the Graham-Cassidy proposal (Graham-Cassidy). This proposal will eliminate affordable quality health care for millions of Americans by gutting the Affordable Care Act (ACA); slash federal funding and destroy Medicaid by turning its funding into per capita caps; eliminate the Medicaid expansion; and defund Planned Parenthood health centers. Graham-Cassidy would leave tens of millions of people in the United States significantly worse off than under current law. Without a full score from the Congressional Budget Office (CBO), we do not yet have a complete understanding of the full devastation that Graham-Cassidy would bring, but what we do know is more than enough for all our organizations to unequivocally oppose this bill. We strongly urge you to oppose the Graham-Cassidy proposal and urge Congress to instead move forward with bipartisan efforts on market stabilization and other critical issues to improve access to affordable health care for all people in the United States.
The ACA and Medicaid are critical sources of health coverage for America’s traditionally underserved communities, which our organizations represent. This includes individuals and families living in poverty, people of color, women, immigrants, LGBTQ individuals, individuals with disabilities, seniors, and individuals with limited English proficiency.
The ACA has reduced the number of people without insurance to historic lows, including a reduction of 39 percent of the lowest income individuals.[i] The gains are particularly noteworthy for Latinos, African Americans, and Native Americans. Asian Americans, Native Hawaiians and Pacific Islanders have seen the largest gains in coverage. The nation and our communities cannot afford to go back to a time when they did not have access to comprehensive, affordable coverage. Further, due to the intersectionality between factors, such as race and disability, or sexual orientation and uninsurance, and issues faced by women of color, many individuals may face additional discrimination and barriers to obtaining coverage if the ACA is weakened as a result of this bill.
Medicaid is also critically important, as it insures one of every five individuals in the United States, including one of every three children, 10 million people with disabilities, and nearly two-thirds of people in nursing homes. Medicaid coverage, including the Medicaid expansion, is particularly critical for underserved individuals and especially people of color, because they are more likely to be living with certain chronic health conditions, such as diabetes, which require ongoing screening and services. People of color represent 58 percent of non-elderly Medicaid enrollees.[ii] According to the Kaiser Family Foundation, African Americans comprise 22 percent of Medicaid enrollment, and Hispanics comprise 25 percent.[iii] Medicaid also serves as a crucial program for Asian Americans, 17 percent of whom receive Medicaid, and Native Hawaiian and Pacific Islanders, 37 percent of whom receive Medicaid.[iv]
People of color are more likely than White non-Hispanics to lack insurance coverage and are more likely to live in families with low incomes and fall in the Medicaid gap.[v] As a result, the lack of expansion disproportionately affects these communities, as well as women, who make up the majority of poor uninsured adults in states that did not expand Medicaid. For people of color who experienced some of the largest gains in health coverage since the implementation of the ACA and Medicaid expansion, the Graham-Cassidy proposal could mean vastly reduced access to needed health care, increased medical debt, and persistent racial disparities in mortality rates.[vi] Further, Medicaid provides home and community-based services enabling people with disabilities to live, work, attend school, and participate in their communities. The proposed cuts would decimate the very services that are cost-effective and keep individuals out of nursing homes and institutions. Finally, one in five people with Medicare rely on Medicaid to cover vital long-term home care and nursing home services, to help afford their Medicare premiums and cost-sharing, and more.
Despite the common myth that all low-income people could enroll in Medicaid, the Medicaid program had previously only been available to certain categories of individuals (e.g., children, pregnant women, seniors, people with disabilities) who had little to no savings or assets. Parents of children and childless adults were often excluded from Medicaid or only the lowest income individuals in these categories were eligible. For example, the Medicaid expansion greatly expanded coverage for LGBTQ individuals who previously did not fit into a traditional Medicaid eligibility category and for working people struggling in jobs that do not offer health insurance and pay at or near the minimum wage. Yet the Graham-Cassidy proposal repeals Medicaid expansion and cuts billions from Medicaid itself which will force states to cut eligibility and services.
We do not yet have a full CBO score that tells us how many people would have Medicaid or marketplace coverage taken away from them under the Graham-Cassidy bill, and we will not have that estimate before legislation may come up on the Senate floor. But the analysis that is already available provides a stark picture, one in which Graham-Cassidy would decimate the Medicaid program as we know it, end the Medicaid expansion, defund Planned Parenthood health centers, and rescind tax credits and cost-sharing reductions currently available to low-income individuals to purchase private coverage.
The Graham-Cassidy bill makes fundamental changes to both the Medicaid expansion and the traditional Medicaid program, as well as dismantling ACA’s reforms to the individual market. Graham-Cassidy destroys the Medicaid program, ending the federal-state partnership and dramatically altering the structure of the program by implementing a per capita cap. The bill would cut billions of dollars of funding to states, limiting the federal contribution to states based on a state’s historical expenditures, which would be inflated at a rate that is projected to be less than the annual growth of Medicaid costs.[vii] Any costs above the per capita caps would be the sole responsibility of states, regardless of the cost of care. As a result, per capita caps will cause deep cuts in care for people with disabilities, seniors, women, and people of color who qualify for Medicaid. Women, who comprise the majority of Medicaid adult enrollees, would be particularly harmed, with women of color disproportionately impacted. Thirty percent of African-American women and 24 percent of Hispanic women aged 15-44 are enrolled in Medicaid.[viii] The move to per capita caps would also disproportionately harm people with disabilities, with home- and community-based services likely targeted for cuts by many states. The move to per capita caps may also give states the option to turn the entire Medicaid program into a block grant.
With regard to the Medicaid expansion, under the Graham-Cassidy plan, ACA tax credits and Medicaid expansion funding would be converted into block grants to states. The Medicaid expansion would effectively end at the beginning of 2020, and the block grants would end entirely in 2026. Graham-Cassidy would cut funding for the expansion under the new block grant system, with funding for the block grants set at 17 percent less than current funding, providing insufficient funds to maintain ACA coverage levels. Beginning in 2021, Graham-Cassidy would also redistribute this reduced federal funding stream across states based on their share of low-income residents instead of their actual spending needs, punishing states that have enrolled more low-income people. Furthermore, and deeply troubling, the legislative language describing what purposes the block grants could be used for is very broad, with no requirement that block grant funds even be used to aid low or moderate-income people.
As the Center on Budget and Policy Priorities has noted, once the block grant funding stops in 2026, Graham-Cassidy would effectively repeal the ACA’s major coverage provisions without a replacement. CBO has previously estimated that this approach would result in 32 million more people being uninsured.[ix] Graham-Cassidy is even more harmful than prior repeal approaches however, in part because states could not continue to cover Medicaid expansion enrollees in Medicaid with less federal funding.
Furthermore, we are very concerned that Graham-Cassidy gives states the option to impose a work requirement as a condition of eligibility under the Medicaid program. Such a requirement not only fails to further the purpose of providing health care but also undermines this objective. Among adults with Medicaid coverage, nearly 8 in 10 live in working families and a majority are working themselves.[x] This work requirement would include penalizing any woman who does not meet work requirements just 60 days after the end of her pregnancy.
In addition, Graham-Cassidy would single out Planned Parenthood by blocking federal Medicaid funds for care at its health centers. The “defunding” of Planned Parenthood would prevent more than half of its patients from getting affordable preventive care, including birth control, testing and treatment for sexually transmitted diseases, breast and cervical cancer screenings, and well-women exams at Planned Parenthood health centers, often the only care option in their area. This loss of funds will have a disproportionate effect on low income families and people of color who make up 40 percent of Planned Parenthood patients.[xi] Seventy-five percent of Planned Parenthood patients are at or below 150 percent of the federal poverty level and half of their health centers are in rural or underserved areas.[xii] One in five women in the United States have relied on Planned Parenthood for healthcare in her lifetime.
Lastly, we are seriously concerned about the lack of transparency of the discussions leading to Graham-Cassidy, and the rush now to vote on the bill without adequate time for analysis, hearings, and a full CBO score, which would provide opportunity for both lawmakers and the public to understand the proposed legislation and participate in this discussion in which their very access to health care for themselves and their families is at stake. It is unconscionable to even contemplate dramatically altering one-sixth of the U.S. economy and taking away health care from millions of people without a full CBO score in hand, along with adequate time to review the CBO’s findings and debate the Graham-Cassidy bill with all the facts.
We urge you to oppose passage of the Graham-Cassidy bill and instead focus on moving forward with bipartisan efforts on market stabilization and other critical issues to improve access to affordable health care for all people in the United States. If you have any questions, please feel free to contact The Leadership Conference Health Care Task Force Co-chairs Katie Martin at the National Partnership for Women & Families (email@example.com), Mara Youdelman at the National Health Law Program (firstname.lastname@example.org), or Emily Chatterjee at The Leadership Conference (email@example.com).
The Leadership Conference on Civil and Human Rights
National Health Law Program (NHeLP)
National Partnership for Women & Families
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Advocates for Youth
AIDS Foundation of Chicago
American Academy of Nursing
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American Association of University Women (AAUW)
American Civil Liberties Union
American Federation of Teachers
American Nurses Association
American Public Health Association
American-Arab Anti-Discrimination Committee
Amnesty International USA
APSE–Association of Persons Supporting Employment First
Asian & Pacific Islander American Health Forum
Asian & Pacific Islander Caucus for Public Health (APIC)
Asian American Drug Abuse Program, Inc.
Asian Americans Advancing Justice | AAJC
Asian Americans Advancing Justice-Los Angeles
Asian Law Alliance
Asian Pacific American Labor Alliance, AFL-CIO (APALA)
Asian Pacific Policy and Planning Council
Association of Asian Pacific Community Health Organizations (AAPCHO)
Association of Programs for Rural Independent Living
Association of Reproductive Health Professionals
Association of University Centers on Disabilities
Autistic Self Advocacy Network
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Black Women’s Blueprint
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Black Women’s Roundtable
Black Womens Roundtable, National Coalition on Black Civic Participation
Black Youth Vote!
Breast Cancer Action
Cascade AIDS Project
Center for American Progress
Center for Community Change Action
Center for Law and Social Policy (CLASP)
Center for Medicare Advocacy
Center for Popular Democracy
Center for Reproductive Rights
Children’s Defense Fund
Children’s Health Fund
Chinatown Service Center
Coalition for Disability Health Equity
Coalition of Labor Union Women
Coalition on Human Needs
Colorado Organization for Latina Opportunity and Reproductive Rights (COLOR)
Commission on the Public’s Health System
Communications Workers of America (CWA)
Community Access National Network (CANN)
Council for Native Hawaiian Advancement
Council of Mexican Federations in North America (COFEM)
Crescent City Media Group
Disability Rights Education & Defense Fund
Drug Policy Alliance
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International Institute of the Bay Area
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Jewish Council for Public Affairs
Jewish Women International
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Korean Community Services of Metropolitan NY
La Cooperativa Campesina de California
Labor Council for Latin American Advancement (LCLAA)
Latino Commission on AIDS
Latinos in the Deep South
Lawyers’ Committee for Civil Rights Under Law
LBGT PA Caucus of the American Academy of Physician Assistants, Inc.
League of United Latin American Citizens
League of Women Voters of the United States
LEAnet, a national coalition of local education agencies
Main Street Alliance
Matthew Shepard Foundation
Medicare Rights Center
Metropolitan Community Churches
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NARAL Pro-Choice America
NASW-NYC Committee on Health
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National Asian Pacific American Women’s Forum (NAPAWF)
National Association of County and City Health Officials
National Association of County Behavioral Health and Developmental Disability Directors & National Association for Rural Mental Health
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National Network to End Domestic Violence
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OCA – Asian Pacific American Advocates
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Raising Women’s Voices for the Health Care We Need
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[i] U.S. Department of Health and Human Services, Affordable Care Act Has Led to Historic, Widespread Increase in Health Insurance Coverage, pp. 2, 4 (Sept. 29, 2016), available at https://aspe.hhs.gov/sites/default/files/pdf/207946/ACAHistoricIncreaseCoverage.pdf.
[ii] Kaiser Family Foundation, Medicaid Coverage Rates for the Nonelderly by Race/Ethnicity: 2015, available at http://kff.org/medicaid/state-indicator/rate-by-raceethnicity-3/?currentTimeframe=0.
[iii] Kaiser Health Foundation, Medicaid Enrollment by Race/Ethnicity, available at http://kff.org/medicaid/state-indicator/medicaid-enrollment-by-raceethnicity/.
[iv] Summary Health Statistics: National Health Interview Survey, 2015, Table P-11a, Age-adjusted percent distributions (with standard errors) of type of health insurance coverage for persons under age 65 and for persons aged 65 and older, by selected characteristics: United States, 2015, ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2015_SHS_Table_P-11.pdf.
[v] Kaiser Family Foundation, The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid, http://kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/
[vi] Center on Budget and Policy Priorities, African Americans Have Much to Lose Under House GOP Health Plan, available at http://www.cbpp.org/blog/african-americans-have-much-to-lose-under-house-gop-health-plan.
[vii] National Health Law Program, Top 10 Changes to Medicaid Under the Graham-Cassidy Bill (Sept. 14, 2017), available at http://www.healthlaw.org/issues/medicaid/medicaid-expansion-toolbox/issues-a-advocacy/top-10-changes-to-medicaid-under-graham-cassidy-bill.
[viii] Guttmacher Institute, Abortion in the Lives of Women Struggling Financially: Why Insurance Coverage Matters (July 14, 2016), available at https://www.guttmacher.org/gpr/2016/07/abortion-lives-women-struggling-financially-why-insurance-coverage-matters.
[ix] Center on Budget and Policy Priorities, Like Other ACA Repeal Bills, Cassidy-Graham Plan Would Add Millions to Uninsured, Destabilize Individual Market (Sept. 18, 2017), available at https://www.cbpp.org/research/health/like-other-aca-repeal-bills-cassidy-graham-plan-would-add-millions-to-uninsured.
[x] Kaiser Family Foundation, Understanding the Intersection of Medicaid and Work, available at http://files.kff.org/attachment/Issue-Brief-Understanding-the-Intersection-of-Medicaid-and-Work.
[xi] Planned Parenthood, This is Who We Are, (July 11, 2016), available at https://www.plannedparenthood.org/files/6814/6833/9709/20160711_FS_General_d1.pdf
[xii] Planned Parenthood, The Urgent Need for Planned Parenthood Health Centers (Dec. 7, 2016), available at https://www.plannedparenthood.org/files/4314/8183/5009/20161207_Defunding_fs_d01_1.pdf.