Maybe Just One More Try

Do you like Whack-a-Mole?  I used to really like playing that game at fairs and arcades.  But I definitely do not like health care repeal Whack-a-Mole.  That’s what it  feels like we’ve been playing this year with the never-ending GOP attempts to repeal Obamacare.  Republicans pop up with an attempt to repeal Obamacare, Obamacare cartoon 5the people knock it down by making it very clear they don’t want it, and then next thing you know, Republicans pop up a few weeks later with another (nearly identical) plan, and the people have to jump into action with another “whack.”

And now here we are again, with yet another GOP repeal plan popping up.  This time, it’s the Graham-Cassidy bill, which the bill’s sponsors are trying to present as the kinder, gentler repeal plan.  But don’t buy it – this plan is anything but.  In fact, this repeal plan is the most extreme plan the GOP has offered yet.

Many of you come to this blog through Twitter, so you keep up with lots of political news and are probably quite familiar with this bill already.  So I’m not going to go through all of the specifics of the bill in detail here, particularly because so much of it is similar to the previous bills the GOP has offered.  So I’m just going to talk about a few of the major differences from the prior bills, along with a few points of interest that stood out to me.  For readers who are not already familiar with the Graham-Cassidy bill and would like to learn about it in more detail, I will point you to a few summaries/explainers that I think are helpful at the end of this post.

So, as noted, Graham-Cassidy does many of the things that previous versions of the GOP repeal bills did.  It still:

  • Makes significant cuts in the amount of funding available for premium subsidies and the Medicaid expansion
  • Caps the portion of the Medicaid program that existed before Obamacare (i.e. the non-expansion portion).
  • Allows states to waive out of essential health benefits (i.e. maternity care, prescription drugs, hospitalization)
  • Ends the individual mandate
  • Bans federal funding for Planned Parenthood (i.e. doesn’t allow Medicaid reimbursement)

But on top of those features retained from previous bills, Graham-Cassidy also does some additional things.  It:

  • Takes all of the ACA’s funding for premium subsidies and the Medicaid expansion, puts that money back into one big bucket, then redistributes it to the states in the form of “block grants.”
    • This means that each state is given a lump sum of money, and determines on its own how to spend it.  Each state will set up its own health insurance market or system.  Money that had previously been spent on low income populations (through Medicaid) can now be spent in multiple ways (e.g. for paying providers, for high risk pools, for reinsurance) – it no longer has to be spent on those low-income citizens.  So they may get even less funding than it appears at first glance.  Any program that is funded – even in small part – by this money will not be permitted to pay for abortions.
  • As part of this redistribution through the block grants, states that expanded Medicaid under the ACA will lose large amounts of money.
    • The money taken from them will be sent to states that did not expand.  Overall, this means many blue states (NY & CA are especially affected) will lose money in favor of red states.  But there will be some red states that lose out too, since some of them did expand – notably Arizona, Alaska and Maine.  Axios has a good graph showing how much each state stands to lose or gain.  However, in order to gin up support for the bill, the bill’s sponsors are lying to certain red state Senators, telling them that their states will gain funds, even though they’re due to lose under the bill’s formula.
  • After 2026, ALL block grant funding will end – yup, money that states would use for premium subsidies and the Medicaid expansion, etc. will be completely gone.  The traditional Medicaid program will still be funded, but as mentioned above it will now be capped, so the funding will be significantly reduced.  In a few years, this bill would leave our health care system in a position that is actually worse – more austere – than what we had prior to the ACA.
  • States can request waivers that permit insurers to charge more for preexisting conditions.  Insurance companies will still be required to cover everyone, but they will be able to increase premiums as much as they want to account for a customer’s health condition.   The Center for American Progress put together this chart of how much the likely “surcharge” will be for various conditions:

  • Drops opioid funding: Because of the steep cuts in Medicaid funding, which would have dire effects in many states that are dealing with the opioid epidemic, previous versions of the Senate bill added back some funding specifically directed to fighting the opioid crisis.  This bill retains the Medicaid cuts (as previously noted) but does not add back any money for treating opioid addiction.

The above is not a comprehensive overview, but a list of just some of the things I think are important to know about the bill.  And now, I just want to make a few observations about what’s going on with the process.  First, Republicans are in a major rush to get this bill passed.  Partly, this is for the same reason they tried to rush every version of the bill: the bill stinks.  Republicans want to get the bill on the floor and voted on before too many people realize just how awful it is and how devastating it would be for the country.  They want to vote on the bill before the activists have time to mobilize against it.

But this time around, there’s an additional reason for their haste:  the Senate needs to vote by September 30 in order to use the reconciliation procedure that allows them to pass the bill with only 50 votes (plus Pence as tie breaker).  That date is the end of the fiscal year, and that is when this set of “reconciliation instructions” expires.  Technically they can start again with a new set of reconciliation instructions in the 2018 fiscal year, but it gets a lot more complicated.

Anyway, because the GOP is in such a rush, the CBO will not have time to provide a complete “score” of the bill.  Senate rules require that in order to use reconciliation, they must know the effect the bill will have on the deficit, so Republicans have put extraordinary pressure on the CBO (forcing the CBO to move all other projects to the back burner) to produce at least a preliminary estimate on the deficit number by early next week.  So that will be available.

But the CBO will not have time to produce estimates of how this bill will affect insurance coverage numbers (i.e. how many will lose coverage as a result) or how it will affect premiums.  There is no doubt, based on outside analyses, and the similarity to previous bills, that those numbers would be absolutely dreadful for the GOP.  But conveniently, it works out that they’ll get to vote on the bill without having to endure the terrible PR that would surely result if the public were able to see those number.

Add to that the fact that this bill has had no hearings, no input from outside experts, no markups, no amendments or input of any kinds from Democrats – it’s impossible to put into words what a grossly irresponsible move it is for Republicans to vote on this bill.   It is not an exaggeration to say that they have literally no idea what the impact of this bill will be on the country, on the millions of people whose lives will be affected and on the 1/6 of the economy that is our health care system.

And here’s something else that at least some Republicans – namely swing state Republicans appear not to have thought through:  they’re voting to bring all of the health care funds & decision making down to the state level.  But they have no idea which Party will be running their state in 2 or 4 or 6 years. (I asked health care expert Larry Levitt from the Kaiser Foundation who, specifically, in each State will get to make these decisions on how the new health care system is set up and implemented – is it the Governor alone, or the Legislature?  He said that it depends on the structure of the particular state, but the legislatures will most likely be involved).

I realize that they think Obamacare is so horrible, that anything else would be an improvement.  But the reality is that Obamacare is a fairly conservative system.  Plus, it’s the “devil” they know.  If they bring health care decision-making down to their state, there’s no predicting what they might end up with.*  And it will be very clear to their constituents who to blame if the results aren’t pretty.

And one final point: No one likes a hypocrite, but for me, hypocrisy is near the top of the list of things that tick me off.  And this bill has put a glaring spotlight on the  hypocrisy of both of its two main sponsors.  First is Lindsey Graham, who early on in the repeal attempts made a point of publicizing his concerns about the “process.”  He made it known that he wanted a careful, deliberative process and didn’t approve of the way the House was rushing to a vote on its bill.  But now, not 5 months later, Graham is pressuring his colleagues in the Senate to vote for a bill that will come to the Senate floor through process that’s even more rushed and less transparent than the one he’d previously criticized.  The saddest part of all of it though is that it’s not even surprising.  I tweeted this back in May, because I had a bad feeling we’d arrive at a day like this:

Graham tweet crop.jpg

But much worse than Graham’s flip-flop is the preening behavior of Senator Bill Cassidy.  I’ve been quietly (and sometimes not so quietly) seething for months now over the fact that Cassidy has gotten away with passing himself off as some sort of special, more principled, empathetic Republican when it comes to health care reform.  Back in May, after Jimmy Kimmel shared the emotional story about his son who needed open-heart surgery just days after he was born, Cassidy appeared on CNN and proposed a “Jimmy Kimmel test” for any GOP health care bill.  Cassidy’s states criteria was that a child born with congenital heart disease would be able to get everything he or she needs in the first year of life.  Kimmel then had Cassidy on his show to talk about that idea, and Cassidy reiterated that pledge

This appearance on Kimmel almost certainly exposed Cassidy to a whole new audience, including many people who probably don’t normally pay much attention to the nitty gritty of policy details or even to politics in general.  And to anyone watching Kimmel that night who was worried about taking care of their family, it appeared like Cassidy was offering security & reassurance – nobody had to worry, this good guy Cassidy was looking out for them, making sure their family would have the health care they need.

But since then, Cassidy has done nothing but betray this promise.  Even before he started pushing the Graham-Cassidy bill (which clearly violates the Kimmel test in numerous ways), Cassidy eagerly hopped on board to support the earlier versions of the GOP repeal bills, which also violated the Kimmel test by letting insurance companies choose not to cover certain health conditions (“essential benefits”) and by bringing back annual and lifetime caps on coverage.  Under the previous GOP bills and under Graham-Cassidy, a baby like Kimmel’s might not have his condition covered at all, or if he did, he’d likely hit his lifetime cap before he even left the hospital.

So I tweeted @JimmyKimmel a bunch of times over the last few months, hoping he’d call Cassidy out on this hypocrisy.  All those families who saw Cassidy on Kimmel that night and thought they were being protected needed to know that it wasn’t true, that their coverage and their kids’ coverage was at risk. Of course I knew there wasn’t much chance that Kimmel would see a tweet from little old me, but I was so frustrated and disgusted by this fraud Cassidy was perpetrating on the American people, I just kept trying anyway.  But nope, I wasn’t successful.

Kimmel tweet crop.jpg

However, now that Cassidy’s own bill may be on the verge of becoming law, a few people with bigger megaphones than mine are also pointing out his gross hypocrisy.  Jennifer Rubin of the Washington Post wrote a great article about it earlier this week.  And what do you know, Jimmy Kimmel took notice and decided he wanted to send a message to his nearly 10 million Twitter followers:

And then Tuesday night on his show, Kimmel called Cassidy out in his monologue, saying that Cassidy “lied right to my face.” And man, was it refreshing to hear Kimmel to come right out and say that!  Political journalists and pundits seem to be so nervous about using the word lie, even though there is so much outrageous, blatant lying going on in Washington these days.  It was really satisfying for Kimmel just call it what it is.

Kimmel went on to say – accurately – that Cassidy’s bill is even worse than the bill the GOP tried to pass over the summer.  He detailed a bunch of the bill’s flaws, and explained some of the ways the process is a complete travesty.  So I was pretty psyched see that first tweet from Kimmel and even happier that he chose to address the issue on his show. You can watch the whole thing in the Tweet above – it’s pretty awesome.  And now there’s just that one minor issue we’re still left with: that Cassidy’s bill might be days away from passing into law.  Let’s see if we can muster one final whack to send this latest repeal mole scurrying back underground.


*NOTE:  Many states – particularly swing states – are so gerrymandered in the GOP’s favor right now, that it might be rational for these Senators to bet on the fact that Republicans will remain in power.  But of course, there’s no guarantee of that, especially if there’s a particularly strong Democratic wave election.  Also, all of that rides on the outcome of the upcoming Supreme Court case on partisan gerrymandering, which I discussed in D.C. Deciphered’s most recent post.


Now here are the promised summaries/explainers for those who want to know more about the basics of the Graham-Cassidy bill:

First the New York Times has nice summary that uses bullet points along with some brief explanation.  This is a good one for those who want a quick tour of the provisions of the bill.

If you want to follow that up with some examination of the real life effects of these provisions, Sarah Kliff at Vox and Jonathan Cohn at the Huffington Post both offer up good, relatively brief pieces.

And it you like to really get into the details of the bill, take a look at these articles from the crew at CBPP and Timothy Jost at Health Affairs (the CBPP piece is straighforward but detailed, Jost’s is more technical).

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