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As of September 26, it appears that the Senate will not have enough votes to pass the Graham-Cassidy health care bill. However, the proposal’s approach to replacing Affordable Care Act (ACA) coverage programs with state block grants is likely to be included in future legislative efforts. The Congressional Budget Office will not release comprehensive estimates of the Graham-Cassidy bill’s effects on health insurance coverage this week, and the agency’s preliminary estimates of the bill’s deficit impacts emphasize the uncertainties around any future coverage estimates. We have produced coverage estimates for the repeal-and-replace bills considered by Congress since November 2016, but we have not produced them for the current bill. Why not? Why is it so difficult to produce these estimates quickly?

The reason is simple: the current bill leaves the future of American health care to individual state decisions. By converting current funding for health insurance coverage (through the Medicaid expansion and the ACA’s Marketplaces) into block grants to states, this bill allows for 51 different policies to be enacted. The variations would depend entirely upon the policy objectives, political interests, political will, and administrative capability of each state and the District of Columbia. And each time the Senate changes the formula allocating block grants and Medicaid funding across states, as it did multiple times in this process, the amount of money available to each state would change along with the ways that money would be used.

Click here to view map of projected state-by-state changes in 2020–26 federal health spending under Graham-Cassidy

Click here to view map of projected state-by-state changes in 2020 Medicaid enrollment under Graham-Cassidy

Click here to view map of projected state-by-state changes in 2026 Medicaid enrollment under Graham-Cassidy