Murkowski again lands in the middle of the national health care debate

WASHINGTON — Alaska Sen. Lisa Murkowski says she doesn't care to be the eye of yet another congressional health care storm, but there she is again.

In crowded Capitol Hill hallways, reporters rush to catch her coming to and from votes. They want to know how she plans to vote on the latest legislation to repeal the Affordable Care Act, known as Graham-Cassidy.

She hasn't decided, she tells them. She still has questions about how it would impact Alaska; she's still crunching the numbers. She's still deciding if Alaska can work with the bill's major overhaul of how Medicaid operates.

"So I think sometimes people get a little perturbed because I'm not just quick to say, 'Yeah, I'm in,' or 'Yeah, I'm not.' I actually want to understand how this works," she said in an interview.

On Tuesday evening, Murkowski stepped out onto the Capitol steps after a final evening vote (to approve a new member of the National Labor Relations Board). It's a lawmakers-only exit, an effective way to avoid a persistent pack of reporters.

Murkowski often takes the less-trafficked outside route, and it was a warm, sunny evening. On her order, an Alaska Dispatch News reporter was the only one to join her.

The heavy interest in Murkowski's vote stems from her role as one of three GOP senators who voted "no" on repeal legislation in July, tanking a series of last-minute bills the Senate majority leader promised would be altered in a House-Senate conference committee. Then, too, she kept people guessing up until the vote.

Murkowski, a moderate, is known to take as much time as possible to decide before more partisan votes. And this one is partisan: No Democrats are expected to vote in favor of Graham-Cassidy if it reaches the Senate floor.

Alaska's other senator, Republican Dan Sullivan, also hasn't promised his vote, though he voted in favor of repeal legislation in July. Sullivan told Fox News on Wednesday that he finds the bill's effort to hand more decision-making over to the states "compelling."

"If you're for federalism, if you're for the 10th Amendment, this has a lot of attraction," Sullivan said.

On Wednesday, a spokesperson for Senate Majority Leader Mitch McConnell indicated he planned to bring it to a vote next week.

But Murkowski still has a lot of questions, she said Tuesday evening. Her staff is still looking to see how changes to the law would impact Alaska, in terms of both Medicaid and individual health insurance plans.

The major focus of the legislation is to shift funding to a "block grant" program — give the money to the states and let them work out health coverage individually.

"And so there are some who are suggesting that block grants are just good, because they give you flexibility. And I don't disagree with that. …

"But it really does matter about the money," Murkowski said. Alaska Gov. Bill Walker "suggested — he says, you know, flexibility is good. All governors want flexibility to their states. But if you're given half the money, that doesn't help me."

[Walker joins other governors in opposition to latest ACA repeal attempt]

Some critics of the plan — including health and consumer groups like the American Medical Association — say the bill would likely leave millions of people uninsured and upend protections for many Americans living with pre-existing conditions.

Insurance companies would technically not be allowed to deny someone coverage based on pre-existing conditions, but states could allow insurance companies to deny coverage for certain treatments and conditions.

States would have more choice in how to regulate their insurance industries, including what counts as an "essential health benefit" — coverage that must be included in a plan. And instead of subsidies, states would get block grants and decide how to spend the money themselves.

[Under latest health care bill, Republican states would benefit disproportionately]

The bill eliminates the mandate that people and employers purchase insurance or face a penalty. Young adults would still be able to stay on their parents' health insurance until age 26.

There would be no more subsidies based on income, age or geography. The current cost-sharing subsidies for the individual market would end in 2020.

Insurers could charge older customers up to five times what they charge younger customers. Currently the limit is a multiplier of three.

Murkowski said, while there are broad numbers available, the actual financial impact to Alaska is still unclear.

"So you got all this stuff, and again making sure that we actually have numbers that show us where we are. I'm not good with a plus or minus a half a billion (dollars) — because that's kind of where we are right now."

Murkowski said she has been in touch with Walker in recent days, and that he needs more certainty as to the incoming federal funding and the in-state obligations.

Though Murkowski spent the summer advocating for a bipartisan, committee-driven process, she said Graham-Cassidy doesn't preclude that, and she continues to encourage the health committee leaders "to pursue a bipartisan outcome."

And Graham-Cassidy doesn't come into play until 2020, she said. "What happens in between now and then?"

That flexibility for the states is the central benefit of the GOP bill, Murkowski said, "allowing the states to basically create their own approach."

But Murkowski said she still has concerns about fundamentally changing how Medicaid works — instituting per-capita caps on spending — through such quick legislation, but she's open to it.

The left-leaning Center for Budget and Policy Priorities said Alaska could see a $149 million cut in Medicaid funding. For states that expanded Medicaid to people living at 138 percent of the poverty line, like Alaska, the federal government would scale back its proportion of payments in 2020.

The "bigger, broader picture does include an entitlement program that is not on a sustainable track," Murkowski said. That does concern her, and she's not opposed to reeling in "the unlimited checkbook that Medicaid currently has."

Overall, Alaska could face a cut of $844 million in 2027, according to CBPP.

Murkowski cited a recent analysis by Axios that showed a potential loss to the state of zero to $1 billion. The numbers were a bit broad for her taste.

A study released Wednesday by Avalere, funded by the liberal Center for American Progress, said Alaska would lose $1 billion in funding through 2026, a loss that totals $2 billion by 2027, and $14 billion for 2020-2036.

That's a third of the state's federal funding for health care. The Center for American Progress projected 41,000 Alaskans would lose health insurance coverage.

"And what we have now is not working, and I want to make sure that whatever it is that we do going forward works. It may be that Graham-Cassidy is the greatest thing. But I need to be able to confirm that," Murkowski said.