WASHINGTON — As the Senate's last-ditch effort to repeal the Affordable Care Act with only Republican votes skidded to an unceremonious end Tuesday, staff for Alaska's lawmakers were still running the numbers.
It doesn't matter now; there will be no vote on the so-called Graham-Cassidy legislation. But the broader outlines of the legislation, and concessions won for Alaska, could direct the path of future legislation, according to the state's two U.S. senators.
In the end, neither Sen. Lisa Murkowski nor Sen. Dan Sullivan were willing to say definitively how they would have voted if the GOP health care bill had gone to the floor for a vote Wednesday. Instead, both pointed to things they like and things they didn't, and an overall lack of clarity on what it all means for Alaska.
The clock simply ran out, they said.
It's easy to get the impression from both of them that if GOP leaders had started with Graham-Cassidy months ago, they wouldn't be in this position, that they would have found a way to agree with their party and vote "yes" on the legislation to "repeal and replace" the Affordable Care Act.
But Murkowski, in particular, may just be reveling in the option of having it both ways. While there was much more she said she likes in Graham-Cassidy than in prior bills, the issues that nominally kept her from joining her party in an affirmative vote in July still remained. There was no bipartisan, committee-led process. There were major questions about whether the bill would protect the health insurance of people with pre-existing conditions. The bill still defunded Planned Parenthood.
Even so, on Wednesday morning, President Donald Trump seemed to indicate that he'd heard positive indications about the Alaska senators' potential votes on the bill, and said they could have gotten there — just not by the Sept. 30 deadline. (The Senate parliamentarian ruled that the Budget Reconciliation, which allowed the Senate to pass the bill with only 50 votes, instead of 60, expired at the end of the fiscal year.)
"It's one thing to have this big broad concept of we're going to give maximum flexibility to the state, we're gonna give block grants, but it all comes down to formulas and base considerations," Murkowski said. "So validating the data really mattered."
In the end, they weren't able to come up with any final answers.
"So the reality is, we were not in a position to support the contours of what had been laid down," Murkowski said.
That was the closest she would go to saying that she was maybe a "no" on the bill, if it had come up for a vote this week.
Otherwise, the senior Alaska senator made clear that she likes the direction the bill was taking, and did want to pass repeal legislation.
"I happen to think that some of the proposals that Graham-Cassidy has in its draft right now are something that I can get more closely aligned with than what we saw with previous products," Murkowski said.
The "status quo when it comes to health care in this country is not acceptable. People are paying too much for their premiums. They're paying too much for their deductibles," she said.
Asked how he would have voted Wednesday if the data remained incomplete, Sullivan said he didn't want to get into "hypotheticals."
Sullivan said he did like the overall approach of the bill — handing federal Affordable Care Act taxes back to the states to create their own programs.
"I thought the vision and the structure was compelling, but hopefully you've seen in my relatively short time here (that) I'm someone who really, really, really tries to do my homework. I read the bills. I edit the bills. I get amendments made to the bills when I think they help the state," Sullivan said. With Graham-Cassidy, "we did run out of time."
They were trying.
Alaska Gov. Bill Walker sent "pretty much his entire team to come and be here this week," Murkowski said. "They spent over six hours with the folks from (Centers for Medicaid Services) and from (the Department of Health and Human Services) going through assumptions, data, the whole works."
Sullivan said he was pleased with the advances he, Murkowski and Gov. Walker were able to make to address Alaska's high cost and other "unique" issues. That included the last-minute changes released Sunday night, assumed by many to be a bid for Murkowski's vote.
"I was pressing for all those changes and I have no problem saying I was — relentlessly, for months," Sullivan said.
Both senators touted a statutory change the bill would have made to the percentage of matching funds that the federal government would have to pay for Medicaid, known as the Federal Medical Assistance Percentages. The federal share in Alaska is 50 percent, the lowest the number goes, a number equaled by 13 other states, according to the Kaiser Family Foundation.
Murkowski said she worked on raising the FMAP with Sen. Ted Stevens years ago, but they never managed anything that wasn't temporary.
The new FMAP formula language, which would have boosted Alaska to 65 percent — solidly middle-of-the-pack — was drafted and offered by Sullivan's office, he said. He's been working on it since December, he said.
The current formula "simply looks at per-capita income. That's it — without looking at the corresponding costs of how much it costs to live in the state and how high the medical costs are," Sullivan said, calling it "unfair."
The latest bill also included language to protect the funding Alaska already has for its "1332 waiver" that offers funding to the individual market, and boosted funding for "Frontier" states.
"We've been briefing them relentlessly on our unique issues," Sullivan said of bill sponsors Sens. Lindsay Graham, R-S.C., and Bill Cassidy, R-La. The provisions weren't "to buy off votes," he argued. "No. They were good policy."
Sullivan and Murkowski were split in their enthusiasm for reshaping the Medicaid program. Both say the program's current spending track has long-term sustainability problems. Murkowski hedges, however, that she worries about reshaping the entire program in conjunction with repeal of the Affordable Care Act.
"The FMAP adjustment is considerable for Alaska," Murkowski said. It could mean hundreds of millions of dollars a year. It may not have addressed the full extent of the state's high costs, but it would have helped, she said.
But "keep in mind that the way the block grant was structured … we were going to be a net loser," even taking into account the additional money for "low-density" states, Murkowski said.
In the early years under the block grant system, "Alaska looks pretty darn good," Murkowski said. "But by the time you get into year 2025, 2026, it's not so good."
And Murkowski had other concerns, including whether the bill adequately supported protections for people with pre-existing conditions.
Murkowski said the issue remains important to her, and she hedged on whether Graham-Cassidy would undercut those protections. "But it still was not airtight. And that was a concern," she said. "The same holds true on lifetime caps."
And like this summer, Murkowski said she had concerns about the fast pace of a bill that didn't move through relevant committees and wasn't subject to the usual amendment and debate process.
She said her concerns about process and policy were echoed by Alaskans at home, particularly this weekend, when she hit the Anchorage farmers markets and the museum to chat with whomever she saw. Many people struggled to articulate why there were opposed to the bill, she said. But she heard plenty of constituents who thanked her for being thoughtful about the effort.
Now, Murkowski said she wants to get back to health committee hearings that began earlier this month, and build on the discussions held there.
She also wants to move the discussion beyond insurance "and who's required to have it, and who's required to provide it, and how we redistribute money to make sure that there is coverage. We have got to get to the health care costs."
During the GOP lunch meeting Tuesday — at which the majority leader announced the bill would not go to a vote — Murkowski was seated with Graham, and told him her idea of having a series of forums on health care up in Alaska. Graham asked if he could come (though he declined an offer to visit in January), she said.
"So I'm going to take him up on his offer. Which, again, if you can get people intrigued with your state, and then willing to help you, that makes all the difference in the world," Murkowski said.
Sullivan said he's hopeful that going forward, Alaska's "case" for reform has been made, across Congress and the Trump administration. "So that's progress, and my view is we'll live to fight another day," he said.