Democrats once liked a federalist solution to health care, and Sen. Lindsey Graham was one of those who worked with them. In 2007 he and Wisconsin Democrat Russ Feingold proposed the State-Based Health Reform Act that would have given states even more freedom than Graham-Cassidy. But these days Democrats fear that state laboratories would discredit the command and control approach to health care that they hope will lead to single-payer. The choice Republicans face isn’t between Graham-Cassidy or some bipartisan beau ideal. Their choice is to pass their own bill, which now means Graham-Cassidy, or fail again and cede the health-care advantage to the single-payer wing of the Democratic Party.
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Based on estimates, overall federal funding for coverage expansions and Medicaid would be $160 billion less than current law under the Graham-Cassidy bill over the period 2020-2026. Thirty-five states plus the District of Columbia would face a loss of funding. Federal funding under the new block grants would be $107 billion less than what the federal government would have spent over the period 2020-2026 for ACA coverage. A typical Medicaid expansion state would see an 11% reduction in federal funds for coverage compared to an increase of 12% in a typical non-expansion state.
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Two GOP senators are likely “no” votes: Kentucky’s Rand Paul and Maine’s Susan Collins. But Arizona’s John McCain, who spoiled this summer’s attempt at ObamaCare repeal, seems unlikely to repeat his performance and sandbag his good friend Lindsey Graham. That means the 50th vote will come down to Alaska’s Lisa Murkowski, who says she’s still trying to decide how the bill will affect her state. If Ms. Murkowski is honest with her constituents—and about her numbers—Alaska needs a “yes” vote.
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As the Graham-Cassidy (Heller-Johnson) health care bill appears to achieve a rapid intensification of support, so too have lies and exaggerations about its contents. Some people are very mistrustful about the states’ willingness and ability to provide a regulatory environment in which broad segments of society will have decent health care. The competency and motivation of the states needs to be compared not to some fantasy federal government with unlimited resources, constant benevolence and technical competence, but to a federal government that in fact is deeply in debt and that has proven itself inept at creating stable health insurance markets.
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The ACA spends more than twice as much on expanding Medicaid as it does on premium tax credits for the exchange. By consolidating funding for both entitlements, Graham-Cassidy allows states to pool resources to increase the attractiveness and stability of the individual market. In doing this, it meets a clear need, but it also facilitates more thorough reform by repealing the individual mandate and potentially allowing fairly priced, fully competitive insurance to be offered outside of the exchanges. It also greatly expands the flexibility and potential uses of Health Savings Accounts. France presses Trump to reconsider climate deal
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The idea of turning more power over to the states has long been advocated by conservatives, but there are compelling reasons for liberals to get behind devolving power from the federal government.
When Congress passed the Affordable Care Act in 2010, it left many of the details to the discretion of the Department of Health and Human Services, giving vast powers to the secretary to determine everything from fast-food menu labeling requirements to when individuals could purchase insurance. During the Obama years, the administration used its regulatory discretion — pushing and arguably exceeding the limits of the law — to prop up the president’s signature legislative accomplishment as the program ran into implementation problems.
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Cassidy-Graham has an important, albeit fixable, flaw—what we might call “asymmetric federalism.” The core idea in the bill is to take the money Obamacare spends on expanding coverage to the uninsured and give it to state governments in the form of block grants. States, in turn, could use these block grants to address the health-care needs of their populations. It’s an attractive idea, in theory. But the bill would put a heavy Washington hand on the federalism steering wheel. It would make it relatively easy for blue states to expand the role of single-payer health care, while making it rather difficult for red states to achieve market-oriented reforms.
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Senate Republicans’ last-ditch attempt to repeal and replace Obamacare rests on the unlikely collaboration of a veteran senator who can’t stand health policy, a wonky freshman who has never passed major legislation and a former senator who lost his seat a decade ago.
Together, Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.) and former Pennsylvania Sen. Rick Santorum crafted the latest GOP repeal bill in hopes of delivering on the party’s seven-year-old campaign promise to repeal Obamacare.
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Interestingly, while trying to craft legislation that would appeal to Republican moderates in the Senate, Cassidy and Graham have created a plan that is in some ways more conservative than the earlier House and Senate repeal-and-replace bills. The Cassidy-Graham bill is comparatively simple and straightforward. It lets states run their insurance markets as they see fit. This is a welcome return to federalist principles that the GOP had forgotten when crafting their earlier ObamaCare replacement bills.
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A crucial GOP senator says that after weeks of effort, there’s not enough agreement among lawmakers to advance a small package of bipartisan changes that would stabilize Obamacare’s health insurance markets. “We have worked hard and in good faith, but have not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders’ hands that could be enacted,” said Senator Lamar Alexander, the Tennessee Republican who leads the Health, Education, Labor and Pensions committee.
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