Fact check: Sen. Cassidy on his health care bill assertions

Sen. Bill Cassidy, R-La., has been touting a health care bill authored by him and Sen. Lindsey Graham, R-S.C. Below are four statements by Cassidy about the legislation and our analyses of them, based on conversations with health care experts.

Statement: "There will be more folks covered under this bill than the status quo, and it protects people with pre-existing conditions." - ABC News interview
Fact check: The Graham-Cassidy bill would scrap the individual mandate requiring people to buy health insurance - the crux of Obamacare, anathema to its opponents - meaning people would no longer be penalized for not having insurance.

James Capretta, a fellow with the right-leaning American Enterprise Institute, told ABC News that the absence of the individual mandate means it would be "highly, highly unlikely" more people would be covered under Graham-Cassidy than under current law.

"Absent other changes, it's likely this kind of approach would encourage and provide an incentive for healthy people to stay out of the market as long as possible and get back only when they need it," he said.

But even if more people will be covered under Graham-Cassidy, other experts said that increasing the number of people who are covered wouldn't mean much if their policies don't cover much.

"States could provide a lot more people with insurance cards in their pocket, but that's not the same as saying there's as much coverage as there is today," Karen Pollitz, a senior fellow at the Kaiser Family Foundation, told ABC News.

Besides the individual mandate, another big difference between the Graham-Cassidy plan and existing law is that the Republicans' proposal would allow states to waive certain requirements - like covering certain essential health benefits and prohibiting higher premiums for people with pre-existing conditions, as long as they inform the secretary of health and human services, who would make the waiver determination, "how the state intends to maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions."

That's much weaker language than in the Affordable Care Act, which allows states to request waivers from requirements under a narrow program but requires them to ensure health care that is "as comprehensive and affordable as would be provided absent the waiver," which Pollitz said is a much more stringent criterion.

Matt Fiedler, a health care policy fellow at the Brookings Institution, agreed, saying the bill would explicitly allow states to get waivers so that insurance companies could charge people differently, depending on "previous health status." He referred to the "adequate and affordable" line in the bill as "toothless."

"The federal government does not appear to have any authority to reject waivers, so states can do essentially whatever they want as long as there is a section on their application materials that pays lip service to this point," he wrote to ABC News in response to questions about the bill. "Even if there were some ability for the federal government to meaningfully enforce this requirement (and an administration interested in doing so), the term 'adequate and affordable' is quite vague and elastic. That would make denying an application on these grounds hard."

Capretta said it's possible that fewer states than expected would request waivers that in effect scrap protections for pre-existing conditions, because those protections are among the popular aspects of the Affordable Care Act.

"States are allowed to come forward with waiver requests, and waivers can be granted, but the politics are not easy on a state level," he said.

The Affordable Care Act's waiver program, known as Section 1332, was geared toward states that wanted to employ "innovative strategies for providing their residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA," according to the Centers for Medicare and Medicaid.

In response to questions about the waiver program in the bill, a Cassidy aide told ABC, "It is fair to point out that states can already approach coverage of people with pre-existing conditions differently through the 1332 waiver process. Graham-Cassidy merely adds another route through which states can apply for waivers to address the insurance needs of their populations, which they are far better situated to do than the federal government."

Statement: "If a state applies for a waiver, it must ensure those with pre-existing conditions have adequate and affordable coverage." - ABC News interview

Fact check: There are two issues with this assertion: There does not seem to be any language requiring waiver-seeking states to meet that criterion, and the criterion is open to interpretation.

"Every insurer must offer every individual a plan and ensure each patient with pre-existing conditions has access to 'adequate and affordable health insurance coverage,'" the Cassidy aide said. But the language in the bill, requiring a proposal for "how the state intends to maintain access to adequate and affordable," is weaker than portrayed by the aide.

Also, the bill contains no metrics for determining whether the state is following through on its plan, nor is there a definition for "adequate and affordable," so that can be left to the discretion of the HHS secretary.

"All in all, it looks to me like Republicans are absolutely determined to do something they can call repeal and replace, even if what they're doing is somewhat incoherent," Capretta said.

Statement: "We also take it through the CHIP program, the CHIP program which is wildly popular, both Democrats and Republicans, used by states to get more people enrolled." - ABC News interview

Fact check: In response to the concern about people with pre-existing conditions, Cassidy said the block grants to states would be funneled through the existing Children's Health Insurance Program (CHIP), which helps states provide health insurance for low-income children.

The comment left several experts scratching their heads.

"CHIP does not regulate insurance markets, so it has nothing to do with regulating where a state ends up on pre-existing condition," said Joan Alker, a research professor at the Georgetown University McCourt School of Public Policy.

While it is true that states are already in the habit of using the CHIP program, Alker pointed out that unlike current Medicaid funds, which are entitled to states and individuals on a long-term basis, CHIP money has to be reauthorized by Congress each year.

"Frankly, the fact that CHIP money is about to expire on Sept. 30 and Congress has not extended it is exhibit A as to why CHIP is not a good model. The Medicaid model is entitlement money. It is guaranteed funding for states," she said.

"Sen. Cassidy is just not telling the truth."

Statement: "States like Maine, Virginia, Florida, Missouri - there will be billions more dollars to provide health insurance coverage." - CNN interview

Fact check: Cassidy mentioned individual states because his bill would change the way states receive money to run their health care systems and help people pay for care, giving states more discretion with the funds but less overall.

A handful of states - including Texas and two of the states Cassidy mentioned, Virginia and Missouri - would end up with a net increase of funding over 10 years, according to a study by the policy analysis group Avalere. But overall, the study found, most states would end up with a net loss of federal funding.

Obamacare-era tax credits, subsidies and Medicaid expansion dollars would be eliminated. Instead, states would receive block grants of money to allocate as they determine. The states that accepted the Obamacare Medicaid expansion would see that money go back into the general pot of funding, the allocation of which would depend on a complicated formula that factors in population size and resident wages, and states would not have to spend money to increase health insurance coverage. Graham-Cassidy block grants would expire in 2026.

But the point is that most states would receive less federal funding because there would simply be less funding to go around and the funding formula would change significantly. States that accepted the Medicaid expansion would lose the most, including not only blue states like New York and California but also Ohio and Alaska, whose Republican governors oppose the bill, and Maine, which Cassidy still mentions as a relative winner despite the fact that it is a Medicaid expansion state and would stand to lose $1 billion, according to Avalere.

So while a few non-Medicaid-expansion states might see more federal funding than they have under the Affordable Care Act, the net result would be a decrease in federal funding - $215 billion, according to Avalere's study.

"In general, the states who expanded Medicaid over the long run are the losers under this formula because the formula tries to normalize funding per person across the states," Fiedler said. "That comparison is a little funny because the nonexpansion states had the option to expand and chose not to. The argument there is an inequity under current law I find a little bit puzzling."

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