This week is do-or-die for the latest attempt to pass Trumpcare. Even with Senator McCain’s opposition to the Graham-Cassidy-Heller-Johnson proposal, this fight is not over until the final votes are taken on the Senate floor. We are not letting up in our effort to ensure that you and your health care are protected. People For the American Way is among the civil rights and LGBTQ equality advocates standing united in opposition to Graham-Cassidy-Heller-Johnson.

You can read our letters in full below.

Civil Rights Advocates Oppose Trumpcare

Dear Senator:

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 protected]), Mara Youdelman at the National Health Law Program ([email protected]), or Emily Chatterjee at The Leadership Conference ([email protected]).

You can view and download this letter, with signers and endnotes, here.

LGBTQ Equality Advocates Oppose Trumpcare

Dear Senator:

On behalf of the undersigned organizations representing millions of people who support equality for lesbian, gay, bisexual, transgender, and queer (LGBTQ) people nationwide, we write to express our opposition to the Graham-Cassidy-Heller-Johnson (Graham-Cassidy) proposal, and its underlying provisions to repeal and replace the Affordable Care Act (ACA). We are deeply concerned about the negative impact that the Graham-Cassidy bill would have on many vulnerable and marginalized communities—including the LGBTQ community—that already face systemic discrimination and healthcare disparities.

The ACA has served as a lifeline for millions of LGBTQ people who too often have found themselves cut off from critical healthcare services.¹ Prior to implementation of the ACA, LGBTQ people had some of the lowest insured rates of any population in the country. The individual market reforms, including the ban on preexisting condition exclusions, have made it possible for many in our community to obtain health insurance for the first time in their lives. Thanks to the ACA, from 2013-2017, the uninsurance rate for low- and middle-income LGBTQ people was reduced by 35%.² There is evidence that this reduction has been greater in states that opted for the Medicaid expansion,³ and currently 1.8 million LGBTQ people rely on Medicaid.⁴ For those with particularly low incomes – under 250% of the federal poverty level – 40% of LGBTQ, compared with 22% of non-LGBTQ people, rely on Medicaid. For many people living with HIV, as one example, protections for those with pre-existing conditions has made insurance affordable and treatment accessible. Tens of thousands of people living with HIV have qualified for care under the Medicaid expansion, gaining access to life-saving treatments before becoming disabled by the virus. As a result, people living with HIV are able to have healthier and longer lives.

The Graham-Cassidy proposal will have a detrimental impact on the positive trend of health coverage for LGBTQ people and so many other vulnerable populations. Under previous repeal and replace legislation with comparable provisions for block-granting Medicaid the Congressional Budget Office projected 32 million people could ultimately lose coverage.⁴ These projections foreshadow an unacceptable growth in the uninsured rate and an equally unacceptable exacerbation of health care disparities.

The Graham-Cassidy proposal fundamentally changes the Medicaid program, imposing a per capita cap funding structure and terminating the expansion of the program under the ACA. The magnitude of the lost funding will have a swift, stark, and devastating impact on the most vulnerable among us: women and children, the elderly, people with disabilities, and persons living with HIV. The legislation also strips the requirement to cover essential health benefits under the Medicaid expansion, leaving millions without access to the critical benefits that often save lives, such as substance abuse treatment and mental healthcare services.

The bill will also increase premiums for people with pre-existing conditions, including many significant, chronic health conditions for which LGBTQ people are at greater risk of experiencing relative to their peers. For example, people with major depressive disorder will see a premium surcharge of $8,490, while someone with breast cancer will see a surcharge of $28,660.⁵ Research shows that 65% of LGBTQ people have a pre-existing medical condition, such as diabetes or heart disease.⁶ Rather than increasing coverage, passage of this bill will cause millions of people to lose coverage while making coverage unaffordable for those who remain in the market.

Graham-Cassidy would give states broad waiver authority to eliminate the ACA’s core protections for people with pre-existing health conditions. Insurers would still have to offer coverage to those with pre-existing conditions, but they could make such coverage so expensive that it would be essentially meaningless. For LGBTQ older adults, many of whom face pronounced health disparities in physical and mental health, including depression, high blood pressure, heart disease, cholesterol, diabetes, obesity, and HIV/AIDS, cost increases of this magnitude would result in the loss of health care coverage.

Prior to the ACA, employer-provided health plans frequently limited the maximum amount of coverage employees could receive over their lifetime. In 2009, 59% of covered employees had health plans with lifetime maximums, meaning they could face bankruptcy if they encountered serious health problems and were left unable to cover their healthcare costs.⁷ By allowing states to seek waivers to specified essential health benefit requirements, the Graham-Cassidy proposal gives states—and subsequently employers—the ability to narrow the definition of these essential health benefits. Ultimately, this would dismantle the ACA’s ban on lifetime limits and annual out-of-pocket spending limits for essential health benefits, once again leaving individuals to risk bankruptcy in order to obtain basic healthcare.⁸

LGBTQ people, particularly people of color and those living with HIV, face systemic discrimination and health disparities, which the ACA was helping to address. Graham-Cassidy would take us backward, shredding the health care safety net and leaving many in our community to risk bankruptcy in order to obtain basic health care. The one-two punch of gutting Medicaid and eliminating the ACA’s marketplace subsidies would strip coverage away from millions and inflict some of its worst harm on LGBTQ people, who already experience health disparities because of economic disadvantage and discrimination.

The provision barring Planned Parenthood and its affiliated clinics from participating in essential public health programs not only violates the procedural requirements of legislation adopted under budget reconciliation, it constitutes terrible health policy. Barring these clinics from receiving federal reimbursement for care provided will jeopardize the ability of these providers to deliver preventive healthcare services, such as cancer screenings and STD and HIV testing, as well as services like gender transition-related care that may not be offered elsewhere in many communities. Often, health centers such as Planned Parenthood offer the only culturally competent healthcare available to LGBTQ people, especially in rural and isolated areas. Rather than improving care options, Graham-Cassidy would disproportionately impact people— including people of color, immigrants, young people, and members of the LGBTQ community— who already face structural barriers to accessing care.

We strongly urge the members of the Senate to reject provisions such as those contained in the Graham-Cassidy-Heller-Johnson proposal that would harm millions of Americans and deny them the health benefits that save lives.

You can view and download this letter, with signers and footnotes, here.