Latest ACA repeal bill could hit those with pre-existing conditions

• Sen. Bob Corker is "encouraged" by the flexibility that states would get.
• The new bill emphasizes block grants, which raised concerns about previous proposals.
• Medicaid would move to a block grant system.

The latest Obamacare repeal-and-replace bill in the U.S. Senate raises the possibility that Tennesseans with pre-existing diseases could see increased costs or change in coverage.

The legislation would hand states broad authority to determine coverage parameters, including the decision to waive community ratings and the essential health benefits. Known as the "Graham-Cassidy" bill, the measure was crafted by Sens. Bill Cassidy, R-La., and Lindsey Graham, R-S.C.

Under the proposal, states could choose to set new regulations on how much can be charged to people with pre-existing conditions who buy insurance on the market, whether insurers can limit benefits over a lifetime, and what insurance plans have to cover, said Melinda Buntin, chair of Vanderbilt University School of Medicine's health policy department.

The language in the bill refers to coverage that people buy rather than getting it through an employer, but could, if enacted, it could have a cascading effect into the employer-sponsored market, said Jennifer Tolbert, director of state health reform at Kaiser Family Foundation.  

It's estimated that between 1.3 million and 2.8 million Tennesseans have a pre-existing condition, according to the Sycamore Institute, which analyzed the impact of an earlier repeal-and-replace bill on rural Tennessee and TennCare.

Joshua Bolin is worried about what the Graham-Cassidy bill, if passed, would mean for his 9-year-old son, who has Type 1 diabetes and a pacemaker. 

The Franklin parent has been watching the string of repeal bills and wondering what they would mean for his son's future. 

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Bolin has hoped that Sen. Lamar Alexander's ongoing effort to strike a bipartisan deal on health care would be successful. Now, he's concerned that Graham-Cassidy will barrel through, without hearings and before the Sept. 30 deadline, at which point the Senate will need 60 votes to pass legislation.

"Most people recognize there are some flaws in the Affordable Care Act," said Bolin. "But there seems to be more of an interest in doing anything that can be labeled repealed or replaced. That's concerning to us. We're not alone — many Tennesseans are far worse off."

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U.S. Sen. Bob Corker, R-Tenn., likes that states would get more control over funding and coverage, and reiterated he wants "an outcome that is better for the American people than what is in place today."

"At present, I am very encouraged by the fact that the Graham-Cassidy legislation repeals the core elements of Obamacare and its one-size-fits-all approach and provides the flexibility governors across our country have been seeking for years,” said Corker.

If passed, the bill would force Medicaid revamp

The full impact of the Graham-Cassidy bill is undetermined, though, if approved, states would emerge with authority to design new health care structures with less federal money. 

The bill would compel states to overhaul Medicaid programs — in Tennessee called TennCare — into a capped system. It would prohibit Medicaid expansion after 2020. 

"It's important to note that this pulls money out of the system," said Tolbert. "States are given this block grant money but it's cut."

It would also eliminate the premium tax credits and cost sharing reductions that make individual insurance more affordable for most shoppers by sending that funding to the states via a block grant, said Tolbert.

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The authority it gives to states makes "it hard to assess" because there could be 50 different approaches to waivers or systems, said Tolbert. 

Graham-Cassidy puts more emphasis on block grants than the previous repeal-and-replace bill. 

Previous legislation that suggested a per capita financing vehicle caused concern about how Tennessee, which runs a lean Medicaid program, would potentially trim services or groups that are covered. 

"This one really emphasizes block grants, which proved to be some of the most problematic elements of the bills that have already failed," said Buntin. "This week will be telling."

It's been almost two months since the Senate voted down the Better Care Reconciliation Act in an after-midnight vote.

And the health care debate, which dominated the national conversation for months, has quieted down as the country faced two hurricanes, threats from North Korea and debates over DACA and tax reform. 

For Bolin, "the speed and manner this would happen is really scary."

The bill does not have a price tag or long-term impact analysis by the non-partisan Congressional Budget Office, but health care experts want people to understand the potential it has to change how pre-existing diseases are covered. 

"People feel safe. They don't know this is coming up and they think this is about other people," said Michele Johnson, executive director of the Tennessee Justice Center. 

Bolin's son, Andrew, doesn't know about the national health care debate and how policy reform could change how, and whether, he's covered in the future.

"He just knows that we get the insulin, the test strips and he gets thousands of shots over the course of the year. His universe revolves around what he needs to do to take care of himself every day," said Bolin. "We haven't had that discussion about what health care is, because as parents that's our responsibility at this stage. (This bill) is the stuff that keeps you up at night as a parent."

Reach Holly Fletcher at hfletcher@tennessean.com or 615-259-8287 and on Twitter @hollyfletcher.