…Here’s where they went wrong.
It didn’t need to be this way.
Squint, and you can see how Graham-Cassidy, the latest Republican repeal bill, could have been the basis for a grand compromise on health care.
To hear Sens. Lindsey Graham and Bill Cassidy explain it, their bill takes Obamacare’s money and hands it over to the states to do with it as they will, unleashing them to be, in Louis Brandeis’s immortal phrase, the laboratories of democracy. Blue states can keep Obamacare or try to build on it — Obamacare-plus, single-payer, whatever. Red states can reject Obamacare and prove that they can get better results by going a different path.
“Instead of a Washington-knows-best approach like Obamacare, our legislation empowers those closest to the health care needs of their communities to provide solutions,” Graham said in a statement. “Our bill takes money and power out of Washington and gives it back to patients and states.”
This would be, as I’ve argued before, the smartest Republican approach to replacing Obamacare. It frees Republicans from making tricky decisions about subsidy levels and structures, about what gets covered and what doesn’t, about how insurers are regulated and how deductibles are managed.
Crafting legislation like this would take work, but Graham and Cassidy seemed ready to do that work. The hyperpartisan, truncated, underinformed, secretive process that led to the previous GOP bills repelled them. As Graham tweeted back in May, “A bill — finalized yesterday, has not been scored, amendments not allowed, and 3 hours final debate — should be viewed with caution.”
And both Graham and Cassidy have good relationships with Senate Democrats. Graham is known for bipartisan cooperation; Cassidy is known as the rare Republican who cared deeply about insurance coverage. If any two Republicans could run a process with hearings, with amendments, with analysis, with bipartisan negotiation, with the time and space to get the bill right, it would be them.
The ugly reality of Graham-Cassidy: But Graham-Cassidy, as it actually exists, doesn’t look anything like that bill, and it’s not going through anything like that process. Instead, it uses federalism as rhetorical cover for gutting spending on both Obamacare and Medicaid, punishing states that expanded health coverage, and violating virtually every policy and process argument Graham and Cassidy have made over the past year.
The legislation would lead to tens of millions of people losing coverage, insurance markets collapsing across the country, and yet more bitter fighting over health care policy. It would make protections for preexisting conditions optional and redistribute funding from states that expanded Medicaid to states that didn’t.
This isn’t a bill that gives states the resources they have now but hands over the control and the tools to innovate and make their health systems better. It’s a bill that slashes the resources states are getting now and leaves them responsible for managing the ugly aftermath. As a careful analysis produced by the left-leaning Center on Budget and Policy Priorities shows, the cuts envisioned in Graham-Cassidy reach $80 billion a year by 2026 — and states are left holding the bag. Making matters both worse and weirder, the bill’s entire funding stream expires in 2027, meaning Congress either needs to reauthorize it or the country’s entire health system falls into chaos:
Center on Budget and Policy Priorities: But the politics of Graham-Cassidy are uglier even than that graph suggests. The complex formula they use to redistribute their shrunken pool of funds punishes states that earnestly expanded Medicaid and tried to make Obamacare’s exchanges work. Asked about these disparities, the bill’s backers have repeatedly argued that it’s just math. “I like Massachusetts, I like Maryland, I like New York, I like California, but I don’t like them that much to give them a bunch of money that the rest of us won’t get,” Graham said.
Of course, that money is available to any state that chose to expand Medicaid, to any state that put real effort into enrolling the uninsured, and it still is. This redistribution from states that tried to make their health systems work to states that didn’t is the reason a number of Republican governors — including John Kasich of Ohio, Bill Walker of Alaska, Charlie Baker of Massachusetts, and Brian Sandoval of Nevada — have come out against the legislation.
Finally, the bill sends its lump-sum payments to the states with few standards or guardrails. States don’t have to build systems that insure more people or as many people; they don’t have to show better results or higher quality care. It’s easy to imagine these payments becoming a slush fund used to make state budgets easier to manage, as has happened in previous block grant programs.
Given these dangers, and given the difficulties of figuring out the right funding formulas and thinking through the needs of different states, you might imagine Graham and Cassidy would hold dozens of hearings, solicit feedback from governors across the nation, and seek amendments from senators representing diverse states. You would definitely assume they’d be working with experts to run deep, thorough analyses of their bill’s likely effects.
But none of that is happening. Graham and Cassidy aren’t even waiting for a full Congressional Budget Office score before moving forward with their legislation, which they’ve decided has to pass by next Saturday because they want it to qualify for the rapidly expiring reconciliation process.
This is a process without the information or the time to fully work out the consequences. No one, including Graham and Cassidy, has any real idea what this legislation would mean for America’s health care system, and they’re not waiting around to find out.
As my colleague Sarah Kliff wrote, Graham-Cassidy is “the most radical Republican health plan to date,” and they’re jamming it through the most bizarre, underinformed, truncated process yet.
A “waste of both of our time”: On Tuesday, I asked both Cassidy and Graham’s offices why they didn’t do this the other way. Why not create state flexibility without joining it to massive spending cuts? Why not go through the normal order and give legislators the time to work through the bill’s details, amend its approach, and build real support? Cassidy’s office never responded. Graham’s spokesperson Kevin Bishop pointed to previous Vox articles critical of Graham-Cassidy and said that answering these questions would be a “waste of both of our time.”
Bishop’s answer is unintentionally revealing: Since winning the White House, Republicans have treated the basic work of legislating on health reform as a waste of precious time. There has never been time to hold hearings, to consider amendments, to negotiate with Democrats, to explain provisions, to consider counterarguments, to work through details.
Republicans justify this mad dash by pointing to September 30, when their ability to use the 51-vote budget reconciliation process in 2017 ends. But that objection is hollow on two levels: They wouldn’t need reconciliation if they could win over Democratic votes, which they haven’t tried, and if that failed, they could spend a few months working on their bill and use reconciliation again next year, or the year after. There is no external force that justifies a process this slipshod and partisan. This is a choice Republicans are making, and it is the wrong one.
Graham-Cassidy is a sweeping, ambitious bill that will completely upend America’s health care system. It has the germ of a good idea in it, and you could imagine a legislative effort building on it toward a worthwhile result. But the bill as written is a mess and the process it’s being jammed through is a disaster. The idea that legislation like this must be passed by next Saturday, even in the absence of CBO analysis or time to discuss and amend, would be farcical if it weren’t so dangerous.
But don’t take it from me. Brookings’ health policy expert Stuart Butler has been pushing federalist health reforms for years. When I emailed him, I expected him to be enthused by Graham-Cassidy. But he wasn’t. “I am a conservative, not a radical, even if I want to see major reform,” he replied. “You just can’t transform the massive health system as quickly as the GOP is trying to do under Cassidy (and other previous approaches this year) without the high probability of really bad outcomes.”
Bad outcomes weren’t the only outcomes possible here. They’re just the ones Graham and Cassidy, for reasons known only to themselves, chose.
