In late July, the long, angry Republican crusade to repeal the Affordable Care Act fell flat on its face. The bills in play, alternatively secretive and rushed—they were put together outside the normal committee process—would have deprived millions of people of health insurance and jacked up premiums in exchange for modest deficit reduction. Understandably, the whole project was massively unpopular. Yet Republican legislators were so set on overturning Barack Obama's signature achievement that "skinny" repeal, as a last-gasp version became known, nearly became law anyway—it took three GOP senators voting against their own party in the dead of night to kill it.
But somehow, in the last week or so, the anti-ACA obsession has regained serious traction. "I just told Bill Cassidy he's kind of the grave robber," South Dakota Senator John Thune, a member of the Republican leadership, said Monday. "This thing was six feet under, and I think he's revived it." Louisiana's Cassidy is, with South Carolina's Lindsey Graham, the senator behind the latest ACA-killing bill—dubbed, somewhat unimaginatively, "Graham-Cassidy." It would bring back all the worst aspects of previous repeal bills and add a few more. And it can only pass via the same unorthodox mechanisms Republicans tried to use this summer and that Arizona Senator John McCain, among others, criticized as inappropriate for such a major bill.
Despite all of that, this thing has a nonzero chance of becoming law—and Americans should be worried about that.
Graham-Cassidy has many features central to previous ACA repeal plans. It would eliminate the mandate for people to buy insurance, kneecap Planned Parenthood by defunding the health provider (for a year), cut subsidies to help people pay premiums, and roll back Medicaid expansion (the ACA component responsible more than any other for people getting insurance). Oh, and it would give states the freedom to let insurers charge sick people more.
The Medicaid rollback part of the bill is more complicated, but the effects would be brutal: According to Health Affairs, the bill's formula for distributing money among states would ignore the tens of millions of people whose income is below 50 percent of the federal poverty line, "a pretty serious underestimate of people who will need financial assistance."
Importantly, this bill would also change how money for healthcare is distributed, doling it out in chunks that state leaders would have wide discretion to use as they please. Cassidy and Graham say that the goal is to spread the money more evenly geographically. "Right now, 37 percent of the revenue from the Affordable Care Act goes to Americans in four states" Cassidy said this week. "That is frankly not fair."
But those four states are California, New York, Maryland, and Massachusetts—in other words, four states with large populations that expanded Medicaid. Red states that declined to expand Medicaid get less from the ACA because they chose to leave that money on the table. As a result, Graham-Cassidy basically punishes blue Medicaid expansion states (as well as some others) and rewards red non-expansion states, while also making Medicaid cuts overall. Those cuts, by the way, would see federal healthcare spending drop by $83 billion, or 34 percent below estimates under current law, by 2026.
It would not be incorrect to call that a cynical bit of policymaking, but it also seems irrational and self-defeating. For one thing, Cassidy's home state of Louisiana expanded Medicaid last year after electing a Democratic governor, and the state health secretary wrote a letter to Cassidy denouncing how the bill "uniquely and disproportionally hurts" their own people. Maine and Alaska also come out losers, which won't help get Susan Collins and Lisa Murkowski get on board; those two Republican senators were instrumental in defeating the last ACA repeal bill. Finally, the damage it does to California and New York in particular might torpedo Graham-Cassidy's chances of passing the House, where Republicans from those states supported repeal last time.
Another problem: As is the case with virtually all complex, sweeping pieces of legislation, it's difficult to understand Graham-Cassidy without a breakdown from the nonpartisan Congressional Budget Office. That's the agency charged with forecasting how much any given law would cost or save the country and, in the case of healthcare, how many people would lose or gain insurance. But the CBO won't be able to provide those numbers for "at least several weeks," it announced Monday. That's a big deal, because if Graham-Cassidy doesn't pass the Senate by September 30, it will need 60 votes—not 50, as is the case now under temporary budget rules —to pass. That's going to be an impossible hurdle unless Republicans persuade Democrats to sign on, which they won't.
Affordable Care Act haters are pushing ahead anyway, with the Senate Homeland Security Committee set to hold hearings on Graham-Cassidy next Tuesday. It's odd for a healthcare bill to go through that committee, but the prevailing attitude in the Republican Party seems to be that any hearing is fine, whatever—the important thing is rushing to a vote.
The good news for repeal opponents is that it's not clear how this bill gets over the finish line. The problems Murkowski and Collins had with the last version—namely, that it resulted in too many people losing insurance and Planned Parenthood being defunded—are still there. McCain, who wants healthcare reform to go through regular Senate procedure, does not appear to be placated either. Kentucky's Rand Paul, meanwhile, says he'll vote no on Graham-Cassidy because it doesn't do enough to destroy the original healthcare law he loathes. If three of those four senators vote no, Graham-Cassidy is dead.
What has Democrats nervous is that Murkowski and Collins haven't come out and said explicitly that they'll do that, and Paul eventually caved on his alleged principles, and voted for the last repeal bill. Meanwhile, what McCain said on Monday was, "I am not supportive of the bill yet" (emphasis added). To paraphrase a classic exchange from High Fidelity, does that "yet" mean McCain actually does plan to support the bill sooner or later? Or that he won't? If he was against the bill, wouldn't he have just said that?
For now, the idea that the future of American healthcare rests on the shoulders of John McCain and Rand Paul should—and does—scare the hell out of liberals, who thought they were in the clear already. As for the 15 million or so Americans who have benefitted from the expansion of Medicaid and the Children's Health Insurance Program, they'll have to wait a couple more weeks to see if Republicans cut them loose to fend for themselves.
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