One lesson of the Trump era in Washington is that Republican efforts to
repeal and replace Obamacare don’t fare well in sunlight. When these
proposals are confined to internal brainstorming sessions and leadership
conferences, they do O.K. But, once they are sent out into the world and
exposed to proper scrutiny, they tend to shrivel up and die.
The latest G.O.P. effort, a piece of legislation put forward by Senator
Lindsey Graham, of South Carolina, and Senator Bill Cassidy, of
Louisiana, will hopefully meet this fate. But nobody should take that
outcome for granted. Republican senators have until September 30th to
enact health-care reform with just fifty-one votes—rather than sixty—so
the Party leadership is looking to ram through the Graham-Cassidy bill
before the American public realizes how awful it is.
Rushing the bill through this way is about the only way it could pass.
Several previous Republican bills were doomed by the Congressional
Budget Office, which issued analyses detailing how the plans would cause
tens of millions of Americans to lose their health-insurance coverage.
By waiting until last week to finalize their bill, Graham and Cassidy
didn’t leave the C.B.O. enough time to do a proper scoring before a vote
is taken. (On Monday, the C.B.O. said that it would try to produce a limited
analysis by early next week.)
Despite this cynical maneuver, there is no ambiguity about the terms of
the Graham-Cassidy bill. It would roll back the Affordable Care Act’s
expansion of Medicaid, which has enabled about fourteen million
Americans to obtain health-care coverage. Then it would subject the rest
of Medicaid to substantial cuts by converting it to a block-grant
program. By targeting the low-paid, the sick, and the infirm, the
legislation would create hundreds of billions of dollars in budget
savings; these could then be applied to Republican tax cuts aimed
primarily at rich households and corporations.
The bill isn’t just a smash-and-grab raid on the poor and nearly poor,
though. It would also undermine the insurance exchanges set up under the
A.C.A., by stripping away the subsidies for the purchase of policies,
abolishing the employer and individual mandates, getting rid of the
lifetime caps on health-care outlays, and allowing insurers to force
people with preëxisting conditions to pay more.
How much more? According to a new analysis by the Center for American
Progress, a liberal think tank, opioid addicts and people with
rheumatoid arthritis would face surcharges of more than twenty thousand
dollars a year. (That’s in addition to the regular premiums.) For people
with serious heart conditions, the surcharge would be more than fifty
thousand dollars a year. And for those with metastatic cancer, it would
be more than a hundred and forty thousand dollars.
In addition to destroying Obamacare, the bill would hand over to the
states some of the money that the A.C.A. raised and let them build their
own health-care systems. (This, supposedly, is the “replace” bit of
“repeal and replace.”) A few big states, such as California and New York,
might try to maintain the current setup, but they would be forced to
spend more of their own money to do so. In a blatantly political move,
the Graham-Cassidy bill would redirect some of the A.C.A. money to the
nineteen Republican-run states that didn’t expand Medicaid, such as
Florida, North Carolina, and Texas.
The authors of the bill probably thought that this was a clever wheeze,
but it could end up backfiring. Some Republican-run states that did
expand Medicaid stand to lose out, including Louisiana, Cassidy’s home.
On Monday, Louisiana’s top health official, Rebekah Gee, wrote an open
letter to Cassidy saying that his bill could cost the state $3.2 billion
in federal funding through 2026, “making Louisiana the 8th biggest loser
of those states affected by the Legislation, and by far the poorest and
sickest state affected by these cuts.”
Cassidy won’t abandon his own legislation, but some of his colleagues
might. On Tuesday, five Republican governors from states that expanded
Medicaid put their names on a letter calling on the Senate not to even
consider the Cassidy-Graham bill. They included John Kasich, of Ohio;
Brian Sandoval, of Nevada; and Bill Walker, of Alaska. “Given Alaska’s
current fiscal challenges, any proposal to shift federal costs to the
states would likely result in drastic cuts to our Medicaid program,”
Walker told the Fairbanks Daily News-Miner.
In another sign that scrutiny is mounting, the American Medical
Association, which represents more than two hundred thousand doctors,
and the American Association of Retired Persons, which has thirty-eight
million members, also criticized the new bill. The A.M.A. said that the
measure “would result in millions of Americans losing their health
insurance coverage, destabilize health insurance markets, and decrease
access to affordable coverage and care.” The A.A.R.P. added that the
legislation would “jeopardize the ability of older Americans and people
with pre-existing conditions to stay in their own homes as they age and
threaten coverage for individuals in nursing homes.”
There can be no doubt that all of this is true. But, as of Tuesday
evening, Rand Paul, of Kentucky, was the only Republican senator to have
said definitively that he won’t vote for the bill. (And it’s worth
remembering that he’s changed his mind on repeal-and-replace measures
before.) Susan Collins, of Maine, has also made critical comments, and
most observers believe that she is a more reliable no vote. Attention
is once again focussing on Lisa Murkowski, of Alaska, and John McCain,
of Arizona. During a dramatic, late-night vote in July, these two
senators both sided with Collins to block the G.O.P.’s last serious
health-care push.
Conceivably, this could come down to another pressure-filled vote, with
the ailing McCain, who is a close friend of Graham, once again center
stage. The Cassidy-Graham bill should never get that far. It represents
a potentially disastrous step backward, and it’s time to shine more
sunlight on it.