After considerable analysis of the Graham-Cassidy health care bill, I discussed its irresponsible essence at New York:
Amateur psychologists everywhere are grappling with the sudden viability of this slapdash piece of legislation that seems to fail so many of the policy tests Republicans set for themselves in earlier debates over how to repeal and replace Obamacare. Most notably, it does not provide for an orderly transition out of the Medicaid expansion (it terminates it abruptly in 2020), and does not offer adequate protections for people with preexisting conditions (states can let insurers charge them crazy-high premiums). If the bill doesn’t meet basic efficacy standards that key lawmakers have already publicly wed themselves to, why does it now seem quite possible that it might pass and throw a multi-trillion-dollar sector of the economy into chaos?
The prevailing explanation is simply that Republicans have run out of time to redeem their incessantly repeated promise to repeal the Affordable Care Act, and this bill, for all its obvious flaws, is the only available measure that hasn’t already been rejected by the Senate. And that may ultimately be the rationale for heaving this gummy mess across the finish line.
But there’s an equally basic motive that makes this particular bill an ideal vehicle for bringing the frustrating cycle of failed GOP health care legislation to a merciful close: More than past templates, Graham-Cassidy allows members of Congress to shift many real and consequential decisions on health-care policy to the states. CNN’s Lauren Fox sums it up nicely:
“One big advantage of Graham-Cassidy is that the bill outsources many of the toughest decisions about health care – what to prioritize, how to regulate the marketplace and cover health care for the poor – to the states. Graham-Cassidy allows individual senators to imagine health care policy in their own image even if outside groups have warned a number of states – some even led by Republicans – would lose federal dollars if the bill passes.”
Do those mean old health-care policy wonks mock your claims as a conservative lawmaker that we’re wasting taxpayer-financed Medicaid dollars on lazy able-bodied adults who ought to get off their duffs and get jobs? Let the states, the “laboratories of democracy,” put it to the test and see who’s right! Are you caught between insurers’ complaints about having to cover people with expensive chronic health conditions and the empathy so many have for sick people who can’t get health insurance? Why let Jimmy Kimmel beat up on you when you could just point to the nearest state capital as the proper place to sort it all out!
It’s entirely appropriate that one of the chief architects of Graham-Cassidy is former senator Rick Santorum, who is sort of the Johnny Appleseed of block grants, having run for president twice touting his responsibility for the 1996 welfare-reform bill that “solved” that ancient policy problem by handing it off to the states. Sure, states mostly used their new flexibility over cash public-assistance payments to cut eligibility, and “welfare” was a relatively small part of the means whereby poor people somehow made ends meet. But from Washington’s point of view, the problem just went away.
In reality, Graham-Cassidy would create hellish substantive and political difficulties for state policymakers who would have just two years to put together an entirely new system around the new block grants they would receive. As the New York Times’ Margot Sanger-Katz explains, the states would be flying through the air without a net:
“In contrast with an earlier bill from Mr. Cassidy, which offered a default option for uncertain states, there is no backup plan in the bill. The Obamacare coverage programs would disappear everywhere in 2020, and any state unable to make a plan and submit an application would be ineligible for the new grant funding. If a state succeeds in obtaining the funding but doesn’t have a functioning new system on Jan. 1, 2020, consumers and markets would be thrown into chaos.”
That wouldn’t be the U.S. Senate’s problem, though.
The long arc of federal health-care policy since the 1960s has been to create certain national expectations for care and coverage against a backdrop of states with different needs, different fiscal capacities, and different political dynamics. California representative Henry Waxman devoted much of his long career in Congress to incremental and bipartisan efforts to make Medicaid (and the closely associated Children’s Health Insurance Program, or CHIP) a bit less geographically capricious every year. And the Affordable Care Act’s Medicaid expansion and preemption of the crazy-quilt system of state insurance regulations took the next logical step.
Graham-Cassidy would begin to unravel all those decades of progress toward treating Americans as Americans when it comes to the right to health-care coverage. But much as it would make life more difficult for state policymakers and the people affected by their decisions, it would make life much easier for Republican members of Congress, who would not only “keep their promise” to blow up Obamacare, but would wash their hands of all the devilish complications of health-care policy for years to come. Graham-Cassidy might as well be called the Pontius Pilate Act of 2017.
Not only does this strategy shield them from blame for what individual states go, it allows them to cut grants without any blame for the resulting cuts to services. It’s also a classic divide and conquer strategy. Instead of fighting a single national constituency, there would be a vastly weakened series of states fighting for their citizens if they even believed in the issue.