As I previously pointed out the GOP wants to force through another iteration of Repeal and Replace. And from where I stand as well as many other health care experts this is but far the worst rendition of an affordable health care delivery system. There seems to be near unanimous opposition to the latest health care bill- the Graham-Cassidy bill among major stakeholders.

Shannon Firth the Washingto Correspondent of MedPage pointed out that momentum is building for the GOP’s latest Obamacare repeal effort, most major physician and hospital groups skewered the proposal. Some members of the GOP held their tongues or even welcomed certain new “freedoms” the bill could afford.

Last week senators Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.), and Ron Johnson (R-Wis.) introduced a healthcare bill to pool money that would have been funneled into premium and cost-sharing subsidies and Medicaid expansion and direct it instead to states in the form of block grants. And we should now probably look at how states use federal grants and all the fraud and waste.

The proposal would also repeal the Affordable Care Act’s individual and employer mandates, the medical device tax, and “strengthen the ability for states to waive Obamacare regulations,” according to a Sept. 13 press release posted on Cassidy’s website. It appears the bill will have no committee hearings or markups before coming to the Senate floor for a vote.

With one exception, most physician groups stating a position viewed the bill as dangerous. The new bill “violates the precept of ‘first do no harm,'” said James Madara, MD, CEO and executive vice president of the American Medical Association, in a letter to Senate Majority Leader Mitch McConnell (R-Ky,) and Minority Leader Chuck Schumer (D-N.Y.).

“Similar to proposals that were considered in the Senate in July, we believe the Graham-Cassidy Amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care,” he wrote.

The AMA is especially concerned about repealing the premium subsidies, cost-sharing reductions, small business tax credits, and Medicaid expansion, and described the Medicaid block grants, which would run through 2026 as “inadequate and temporary.”

“Per-capita caps (a form of block grant) fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation,” he wrote.

Rebecca Parker, MD, president of the American College of Emergency Physicians, also penned a letter to Senate leadership highlighting the dangers her members see in the bill.

“ACEP cannot support any legislation that does not include emergency medical care as a covered benefit in health insurance,” she wrote. “Yet, [the Cassidy-Graham bill] allows states to easily forego requiring insurers to adhere to important consumer protections, including the requirement to cover the ten essential health benefits, and protections for those with pre-existing conditions.”

Ninety-five percent of Americans believe health plans should cover emergency medical care, Parker noted, which is currently one of the ACA’s essential benefits.

“Emergency physicians agree with them. Patients can’t choose when and where they will need emergency care, and they shouldn’t be punished financially for having emergencies,” she continued.

And a joint letter from six specialty organizations representing more than 500,000 physicians — the American Academy of Family Physicians, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, the American College of Physicians, and the American Psychiatric Association — described the bill as “disruptive” and “harmful” to patients.

In addition to failing to preserve the coverage and consumer protections enacted by the ACA, the groups said the new bill “would create a health care system built on state-by-state variability that would exacerbate inequities in coverage and most likely place millions of vulnerable individuals at risk of losing their health care coverage.”

The groups continued to urge Congress to pursue “regular order” including hearings, debates, and committee markups and not to rush a vote.

Because the new bill’s approach is similar to previous repeal proposal’s, Bruce Siegel, MD, MPH, the president and CEO of America’s Essential Hospitals, said he anticipates a similar result: “millions of Americans losing coverage. ”

“Unlike those previous proposals, the Graham-Cassidy bill provides no meaningful relief from looming cuts to Medicaid disproportionate share hospital (DSH) payments,” he noted, while stressing that the new bill would also limit “how states raise support for the safety net.”

“Rather than providing flexibility, this would limit states’ coverage and financing choices,” he said.

Similarly, “This proposal would erode key protections for patients and consumers and does nothing to stabilize the insurance market now or in the long term,” said Rick Pollack, CEO of the American Hospital Association, in a press statement.

It is interesting that not all physicians want to see the bill shredded. Despite her “mixed feelings,” Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, said on the whole, “I think that it may in the long-term make things a tiny bit better by permitting a wedge of freedom.”

Examples of this freedom include giving block grants to states and rolling back federal regulation so that states can experiment and make their Medicaid programs more efficient.

“The idea that we can just infinitely expand the money that we’re pouring into Medicaid is going to come to a halt. It has to. How can you keep spending money that you don’t have?” Orient asked.

Half of all Medicaid funding is money coming from creditors, because the government has to borrow 50 cents of every dollar it spends, she said.

The American Association of Neurological Surgeons/Congress of Neurological Surgeons indicated that members like giving states more control over how healthcare dollars are spent, and repeal of the medical device tax. But the group is concerned about “backsliding” on other insurance reforms, such as those involving pre-existing conditions, a press representative told MedPage Today in a phone call.

“Without a [Congressional Budget Office] score, it’s impossible to predict what the states are going to do at this point,” the representative said. No CBO analysis of the bill other than its effect on the federal budget is expected.

Other specialty groups have remained silent on the bill.

Another important set of stakeholders also stated opposition to Graham-Cassidy: the health insurance industry, whose chief trade group declared it “cannot support this proposal.”

Marilyn Tavenner, CEO of America’s Health Insurance Plans, outlined six “guiding principles” in a letter to McConnell and Schumer on Wednesday. They included: stabilizing the individual insurance market, a strong Medicaid program, guaranteed coverage for all, sufficient lead time to implement reforms smoothly, improved affordability, and reliance on the private market.

“The Graham-Cassidy-Heller-Johnson proposal fails to meet these guiding principles,” the letter said, “and would have real consequences on consumers and patients by further destabilizing the individual market; cutting Medicaid; pulling back on protections for pre-existing conditions; not ending taxes on health insurance premiums and benefits; and potentially allowing government-controlled, single payer health care to grow.”

Senate leadership aims to bring the bill to the floor for a vote next week. The body faces a Sept. 30 deadline to pass legislation with budgetary implications without needing 60 votes to overcome a filibuster.

How could the Graham-Cassidy bill affect us all by state what might really happen?

Given the basics — less money but more flexibility with that money — states would have big choices to make. And analyses have shown that Graham-Cassidy would leave millions — even tens of millions — more Americans uninsured than under the status quo.

“You can inject the money wherever you want into the problem of the uninsured, but if there’s less money you’re going to cover fewer people. There’s no two ways about it,” said Nicholas Bagley, a professor and health law expert at the University of Michigan Law School. “Or you’re going to cover as many people but less generously.”

So here are a few routes states could take, according to what a variety of health care experts told NPR. Given all the flexibility states might have, this is just a sampling of what states could do, but it’s a start at conceptualizing how health care in any given state might look if the bill passes.

Let’s focus on demographics. “What is the patient mix? What does the consumer mix look like in your state?” said Lanhee Chen, research fellow at Stanford’s right-leaning Hoover Institution and policy director for Mitt Romney’s 2012 presidential bid. “Those are going to be important factors: demographic factors; patient mix and acuity; is there one dominant employer in the state?”

For example, a state with a large population of Medicaid recipients may want to direct more funding to helping lower-income people. Some states may also allow insurers to charge more for people with pre-existing conditions, meaning those patients may need more help.

Chen used Massachusetts as another example of how a state might decide to reconfigure its health programs.

“The average income is higher; you have people with more educational attainment who are used to making choices on a broad variety of things, where maybe more health care choices would not be problematic,” he said.

Should we boost Medicaid as much as possible? Some analyses have shown that Medicaid covers people for far less than it might cost under private insurance. With that in mind, says one expert, states might do well to just expand Medicaid as much as they can.

“If you wanted to do right for the health of the people in your state what would you do?” asks Amitabh Chandra, professor of social policy at Harvard University. To him, the answer is obvious: “The single most cost-effective thing to do is spend on the Medicaid program. It’s unbelievably lean, but it’s unbelievably efficient in terms of the value it delivers.”

… Or not. On the flip side, a state where lawmakers want less government involvement in health care could take a different route.

“A state could say, ‘We don’t really like putting the Medicaid expansion population back into Medicaid so what we’re going to do instead is help them get private coverage,’ ” said Bagley.

States could also make Medicaid less generous. “In our Medicaid program in Ohio, we probably spend as much money now on optional benefits as we do on mandatory benefits,” said John Corlett, that state’s former Medicaid director. “People forget that a lot of benefits that states provide in the Medicaid program are optional.”

That could save a lot of money, he said, but he added a caveat: “That’s not making the program more efficient.”

What about the help that clinics provide that serve low-income people? As low-income Americans would be the most affected by reduced premium subsidies and shrinking the Medicaid program, one expert says it would be smart to simply direct the money to places that serve the most low-income patients.

“Your choices are just awful,” cautions Sara Rosenbaum, professor of health law and policy at George Washington University — she believes that reducing money available to states both in the block grant and in Medicaid will force lawmakers to leave many of their constituents worse off.

“But the most sensible thing to do would probably be — at least where they’re available — to go to your public hospital or your community hospital or community health centers, and if you have other clinics in the region that see low-income people, to give them some grants and let them care for as many people as they can.”

Shoud they shift money toward (or away from) particular groups? “A state may decide to move money currently used for insurance premiums down the income spectrum”, Chen said.

“The ACA subsidy structure allocates subsidies for people making up to 400 percent of federal poverty,” he said, noting that that comes out to nearly $100,000 for a family of four. “A state like Kansas, for example — they might have a relatively smaller distribution of people that are at that income level, and by the way, most of those people might already be getting offers of health insurance” from their employers, he said (though it’s important to note Graham-Cassidy would also eliminate the employer mandate).

States could “beef up support for people making less than 250 percent of poverty,” he said. “That is something you could pursue under Graham-Cassidy that you couldn’t pursue under the ACA.”

This is contingent upon there being enough money, though, because once again, Graham-Cassidy would reduce federal funds to many states. Yes, it’s a Republican bill, but it grants a lot of leeway … meaning states could use their block grants to move closer to a single-payer system.

“Some states are going to experiment with how they bring more centralization into their marketplace,” said Chen. He hesitated to say single-payer — “I don’t know if there’s enough here resource-wise to make that work” — but he noted that a state might decide to create “some kind of a Medicaid buy-in system.”

Bagley explained how this sort of system might work.

“One alternative would be to take the money and create a state-based Medicaid-type program that paid Medicaid rates and have a Medicaid-type plan cover all the uninsured in the state,” said Bagley. “So it wouldn’t be single-payer, but it would be a single-payer approach for the uninsured.”

For this reason, some Republicans remain displeased with Graham-Cassidy. Louisiana Sen. John Kennedy this week said he was undecided on the bill for this reason.

“If you give California and New York a big chunk of money they’re gonna set up a single-payer system. And I wanna prevent that,” he said, as reported by Bloomberg’s Sahil Kapur.

However, GOP senators remain divided; Wyoming’s John Barrasso responded, “Either you believe in states’ rights or you don’t believe in states’ rights.”

Or I previously mentioned the states may use the money in a way the bill totally does not intend: that is, for things that are totally unrelated to health care. Really??

Though its true Graham-Cassidy specifies ways in which states must use the money, the bill does not stop states from simply using the federal money to take the place of other state spending.

“It’s just so much money, and block grants have a way of being pretty fungible, and states and others will figure out ways to divert these moneys to other purposes if they want to,” said Corlett.

Chandra elaborated on the kinds of choices states could find themselves making.

“I can maybe say I really like the exchanges in Obamacare, and I’m going to subsidize the exchange premiums,” Chandra elaborated. “Or I could decide to build a brand-new football stadium. That’s the degree of latitude we’re giving states.”

I think Senator McCaine said it best as he voiced his indication that he would vote against this bill. He said that he would vote against all unless there was a bipartisan effort in improving the health care delivery system.

“I cannot in good conscience vote for the Graham-Cassidy proposal. I believe we could do better working together, Republicans and Democrats, and have not yet really tried. Nor could I support it without knowing how much it will cost, how it will affect insurance premiums, and how many people will be helped or hurt by it. Without a full CBO score, which won’t be available by the end of the month, we won’t have reliable answers to any of those questions,” McCain said in a press statement.

With opposition already announced by Sen. Rand Paul (R-Ky.), and expected from at least one other senator, CNN and The New York Times, among others, said it appears the bill is doomed.

“I would consider supporting legislation similar to that offered by my friends Senators Graham and Cassidy were it the product of extensive hearings, debate and amendment. But that has not been the case. Instead, the specter of September 30th budget reconciliation deadline has hung over this entire process.”

This is the second time in recent months McCain has sided against his party over repeal efforts. In late July, the Senate’s efforts to pass the so-called “skinny” repeal bill disintegrated after a 49-51 vote, when McCain voted the package down alongside Sen. Lisa Murkowski (R-Alaska) and Sen. Susan Collins (R-Maine). It is really important to listen to Senator McCaine for at this point the Democrats are now willing to be involved in the process. The difficulty here is that they are supporting Senator Bernie Sanders who is pushing a single payer system: Medicare for all. Is this a smart move? We will investigate this concept and its value and frailties in another future post.

Joyce Frieden pointed out further that with the Senate preoccupied with the so-called Graham-Cassidy bill to repeal and replace the Affordable Care Act (ACA), healthcare groups are trying to call attention to other funding bills whose time is running out.

Among the healthcare programs whose funding is set to expire on Sept. 30 are:

The Children’s Health Insurance Program (CHIP), which was enacted in 1997, serves 8.9 million children whose families are low-income but not poor enough to be eligible for Medicaid. At a recent hearing on reauthorizing CHIP held by the Senate Health, Education, Labor, & Pensions Committee, senators from both sides of the aisle expressed support for funding the program.

“In Nevada, CHIP provides coverage for roughly 25,000 children,” said Sen. Dean Heller (R-Nev.). “Nevada has made great strides in improving its uninsured rate … My hope is that Congress will act swiftly … to give families in Nevada and across the country the certainty they need with regard to children’s healthcare.”

“We know that before CHIP was created, millions of hardworking families couldn’t take their children to the doctor and get them the care they needed,” said Sen. Debbie Stabenow (D-Mich.). In that state, 97% of children can go to the doctor.

“That’s a very big deal, and it’s because of changes we’ve made through the ACA and CHIP,” she said. However, despite bipartisan praise for the program, several issues surrounding its renewal have yet to be decided. One of these is whether CHIP’s funding will simply be extended, or whether it will be reauthorized. Reauthorization is much more complicated, noted HELP Committee chairman Orrin Hatch (R-Utah).

To keep the money flowing to CHIP, Hatch and Sen. Ron Wyden (D-Ore.), the committee’s ranking member, on Monday introduced S. 1827, the “Keep Kids’ Insurance Dependable and Secure Act of 2017”. The measure would extend funding for CHIP through fiscal 2022.

“With the entire ACA marketplace subsidy system now operating under a cloud [because of opponents’ attempts to repeal the law] …. it should come as no surprise that senators Hatch and Wyden would have concluded that continued CHIP funding remains essential,” Sara Rosenbaum, JD, a member of the Medicaid and CHIP Payment and Access Commission (MACPAC), wrote in a blog post for Health Affairs.

The National Health Service Corp (NHSC). This program provides scholarships and loan forgiveness to nearly 10,500 primary care medical, dental, and mental health professionals serving in underserved areas. The ACA provided $1.5 billion in funding for this program during fiscal years 2011 through 2015; the Medicare Access and CHIP Reauthorization Act (MACRA) then provided $310 million each year for fiscal 2016 and 2017.

“We have to shine a light on this because it will be a major step backwards if [programs such as NHSC] go unfunded,” Jack Ende, MD, president of the American College of Physicians and an internist practicing in west Philadelphia, said at an event here Wednesday sponsored by the National Coalition on Health Care (NCHC), a coalition of payers, providers, consumers, and other healthcare groups.

What about the Teaching Health Center Graduate Medical Education program? This program trains primary care residents in outpatient care at federally qualified health centers, rural health clinics, and tribal health centers. In the 2015-2016 academic year, the program trained 732 residents. The program started with a 5-year appropriation of $240 million in fiscal 2011 as part of the ACA; funding was extended through MACRA in fiscal years 2016 and 2017 at a rate of $60 million per year.

If the funding for these last two programs is allowed to run out, “Residents [now in training under them] would totally be without any source of revenue [and would] have to reapply to other programs,” said John Sealey, DO, director of medical education at the Detroit Wayne County Health Authority.

Republican congressional leaders are pushing for the vote on the Graham-Cassidy bill by the end of next week because the Senate parliamentarian has given a Sept. 30th deadline for bills dealing with federal spending and revenue to pass the Senate under the rules of reconciliation, which require 50 votes — rather than 60 — for passage (the rule’s “simple majority” actually requires 51 votes, but Vice-President Mike Pence, a Republican, is able to cast a tie-breaking vote if needed).

But Yom Kippur, a Jewish holiday, which begins at sundown on Sept. 29, and ends also confound the Sept. 30th deadline at sundown on the 30th. “Though all nine Jewish senators are Democrats who won’t be voting for the bill, the optics of scheduling a vote when Jewish senators, including the Democratic leader, cannot be there will be difficult to navigate,” notes the Washington Examiner. “In theory, Republicans could hold a vote before sundown Sept. 29 or after sundown and before midnight on Sept. 30 and not be technically voting on the holiday. However, that would make it difficult for any Jewish members to travel home.”

I appeal to all the GOP and the Democrats to listen to those who know more about health care and what will and will not work- work together to improve the health care system and forget the Repeal and Replace.