You can immerse yourself in Medicaid funding.
You can grapple with block grants.
You can take a primer on pre-existing conditions.
Do all that, and you still won’t get what the Graham-Cassidy bill is all about.
That’s because the bill seems to be a political solution to a health-care problem. But it actually is a health-care solution to a political problem.
The fundamental political problem that the bill tries to solve: Republican elected officials have voted and promised for years to repeal and replace the Affordable Care Act, or the more derided name, “Obamacare.”
Now that they have control of all the branches of government, GOP supporters are understandably frustrated that the party has been unable to do what was so easily promised over the last seven years. Their donors are threatening to withhold massive campaign funds, and the president has lashed them for their failures.
They failed to pass the House-passed American Health Care Act in the Senate.
They failed to pass the so-called “skinny repeal.”
And now the Graham-Cassidy bill appears doomed.
It’s not so surprising they failed, though, when you look at these efforts as merely solving a political problem. Graham-Cassidy is in essence a flailing, last-ditch effort to salvage a “win” for the party and the president, not a considered effort to reform the health-care sector.
To grasp that, first recall that the urgency of passing these bills quickly, without any substantial hearings or amendments, comes from a political necessity.
The bills are being considered as part of “budget reconciliation” because, to pass, those votes only need to receive majority support — 51 votes in the Senate. Under that chamber’s usual operations, there must be 60 votes in order to overcome a filibuster. But budget reconciliation ends Sept. 30, hence the hurry to pass Graham-Cassidy now.
With the 48 Democrats united against these efforts, mustering 60 votes for these repeal efforts is impossible. However, the hurry is occurring even as two senators, a Republican and Democrat, have been setting up hearings to proceed deliberately on a plan to fix the health-care system, one that could muster 60 votes.
Like it or not, the idea of the 60-vote threshold is that it forces consideration and compromise. Sen. John McCain pointed to his desire to return to this “regular order” in announcing he would vote no on the bill.
These are also ideas that Sen. Jeff Flake deeply embraced in his book, “Conscience of a Conservative,” but then dispensed when it came to a real-life test — these efforts to repeal the Affordable Care Act by a majority-only vote.
In his book, Flake argues strenuously against removing the 60-vote threshold: “Such a move would turn the Senate into just another majoritarian body just like the House of Representatives, thus forfeiting its reputation as a deliberative body at all, much less the world’s greatest. At that point it might be fair to ask: Why have the Senate at all?”
He even imagined himself confronting a hypothetical effort by Trump to pass tax reform with only majority votes: “I will not support any such effort to harm the Senate. It is a line I cannot cross. Assuming all 48 Democrats would also oppose any such effort, if any three Republicans join them, we could block it.”
And yet, faced with re-election next year and unpopularity among the Republican base, Flake took the opposite tack when it came to this health-care bill. He agreed to go along with an effort to set a major policy by a simple-majority vote. He has a political problem to fix.
These decisions don’t make a lot of sense in the policy context. By all analyses so far, Arizona, as a state that expanded Medicaid under the Affordable Care Act, stands to lose more than the states that did not expand Medicaid.
Nevertheless, it wasn’t just Flake among Arizona Republicans, but also Gov. Doug Ducey who stood in favor of the bill despite the fact that its effects on Arizona were not known yet. Even after the Joint Legislative Budget Committee reported that the bill would result in a loss of $1.7 billion in expected Medicaid funding the first year, Ducey persisted in his support.
He and many senators have explained their support of the bill by reciting a tried-and-true talking point: The block-grant approach and passing decision-making to the states should improve the system by giving the states flexibility to design their own systems.
Of course, the organization of state Medicaid directors said in a joint statement the bill does not give them enough time or money to make this radical, lightly considered transformation of their programs work.
“The vast majority of states will not be able to do so within the two-year timeframe envisioned here,” they said, “especially considering the apparent lack of federal funding in the bill to support these critical activities.”
Nevertheless, in a grimly hilarious story published last week, a Vox.com reporter asked nine senators why they support Graham-Cassidy, and this talking point of state innovation was almost all that they could come up with. They had little idea what else was in the bill.
But there is an unstated motivation when governors and senators declare their support for these repeals: They are under tremendous financial pressure. Big funders of Republican candidates in the Koch network have said they will withhold donations until tax reform passes and Obamacare is repealed.
At a June meeting in Colorado Springs, major Dallas fundraiser Doug Deason declared his “piggy bank” closed for now.
“Get Obamacare repealed and replaced, get tax reform passed,” Deason said in a pointed message to GOP leaders. “You control the Senate. You control the House. You have the presidency. There’s no reason you can’t get this done. Get it done and we’ll open it back up.”
This kind of pressure explains more than any policy details the reason some in the GOP have been rushing to pass anything they can call a repeal. They’ve promised it. They feel they have to deliver it. And if they don’t, they fear they’ll be punished.