Internists Oppose Graham-Cassidy Proposal

Legislation would cause an unacceptable increase in the number of uninsured patients

Washington, September 13, 2017—The American College of Physicians (ACP) sent a letter to Senators Lindsey Graham and Bill Cassidy, sharing ACP’s opposition to their bill to “repeal and replace” the Affordable Care Act’s Medicaid expansion, premium and cost-sharing subsidies with block grants to states to develop their own plans to provide health care coverage to their residents.  ACP also sent a separate letter to Senate Majority Leader Mitch McConnell and Minority Leader Charles Schumer, urging the Senate to set the Graham-Cassidy bill aside and instead advance bipartisan improvements to current law through a more deliberative process of regular order that allows for hearings, amendments, independent expert review, and input by those directly affected.

The letters, from Jack Ende, MD, MACP, president of ACP tell the senators that, “substantial cuts to Medicaid authorized by this legislation would cause a significant increase in the number of uninsured patients and that it would undermine essential benefits provided for patients insured under current law.”  ACP has developed criteria, 10 key questions, that should be asked to ensure that any legislation that would alter the coverage and consumer protections under current law first, do no harm to patients and ultimately result in better coverage and access to care for essential medical services.  The letters stressed ACP’s concern that the Graham-Cassidy legislation falls well short of meeting the criteria that ACP established to ensure that the health of patients is improved rather than harmed by changes to current law.

The letters detail ACP’s areas of concern in four areas:

  • Eliminating the enhanced federal match provided under the ACA for Medicaid expansion, capping and cutting the federal contribution to Medicaid, replacing guaranteed federal funding with optional block grants, and allowing states to impose work requirements under Medicaid that would cause millions of the most vulnerable to lose coverage.
  • Replacing the ACA’s premium tax credits and cost-sharing subsidies with a discretionary formula would result in less funding than currently in place for individuals to purchase health insurance in the individual market.  ACP is also concerned that states could use these funds for a broad range of health care purposes, not just coverage, with essentially no guardrails or standards to ensure affordable meaningful coverage.
  • Allowing waivers for state innovation and essential health benefits would weaken consumer protections such as essential health benefits guaranteed under current law.
  • Eliminating the requirement that individuals buy insurance would allow individuals to wait until they are ill to purchase insurance; insurers would then need to increase premiums to compensate for the resulting sicker risk pool. Congress should not enact any legislation to weaken or repeal the individual insurance requirement absent an alternative that will be equally or more effective.

“In July of this year, the Senate failed to garner the necessary votes in the process of moving forward with legislation to repeal and replace the ACA in a budget reconciliation bill.  Rather than continue with an effort to repeal and replace the ACA, ACP urges you to set aside this legislation and instead, focus on bipartisan efforts to stabilize the health insurance marketplaces, create competition among insurers, and lower the costs of health care for all Americans,” Dr. Ende concluded. “We also urge that any legislation to amend current law should be developed through regular order, with hearings, debate, and committee mark-ups, and with sufficient time for independent analysis by the Congressional Budget Office (CBO), independent experts, and the clinicians and patients directly affected by the proposed changes.” 


The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 152,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.