Op-Ed

Repeal and replace is back, and scarier than ever

Like the villain in a slasher movie, Senate Republicans keep coming for the health insurance of tens of millions of Americans. After Sen. John McCain’s dramatic “no” vote seemed to finish off this year’s attempts to repeal the Affordable Care Act, a proposal by two senators with mostly unearned reputations for moderation — Bill Cassidy (R-La.) and Lindsey Graham (R-S.C.) — represents the latest threat to the many people who gained access to healthcare under President Obama. The scariest part is that it might just pass.

Cassidy-Graham follows a recognizable conservative template. The ACA’s Medicaid expansion and tax credits to purchase insurance from the private market would be eliminated and replaced with block grants given to the states. When a Republican proposes a “block grant” this almost always means a big spending cut, and Cassidy-Graham is no exception — it would reduce federal healthcare spending by about $400 billion in less than a decade. And not only would it end the Medicaid expansion, it would entail savage cuts to Medicaid as a whole. In another retrograde move, the bill would effectively end the ACA’s protection of people with preexisting conditions, as states could choose to allow insurers to charge people with such conditions higher premiums.

For a brief period earlier this year, Cassidy presented himself as the GOP’s moral conscience on healthcare. In response to late-night TV host Jimmy Kimmel’s viral monologue about his newborn son’s heart condition, Cassidy proposed what he called the “Kimmel test”: “Would the child born with a congenital heart disease be able to get everything she or he would need in that first year of life ... even if they go over a certain amount?”

Guess what? Cassidy-Graham fails Cassidy’s test miserably. Millions of people would lose insurance, and many more would be effectively locked out of private markets as subsidies became less generous and states allowed insurers to discriminate against people with preexisting conditions. As with the previous Republican proposals, the effect of Cassidy-Graham would be increases in preventable death, suffering and financial ruin. But we don’t even know how many people will lose coverage, because the Congressional Budget Office won’t have time to properly score the bill before the Sept. 30 deadline to pass it under reconciliation rules. (We do know the number will be large.)

So why might Cassidy-Graham succeed where other Republican proposals failed? It thrusts responsibility on the states. Federalism has long been a valuable tool for reactionary public officials acting in bad faith. It’s a lot easier to defend an attractive-sounding abstract principle like “state sovereignty” than to defend, say, segregation on the merits. Cassidy-Graham is in this ignoble tradition, shifting the discussion away from policy changes that would be immensely unpopular if made directly by invoking the “flexibility” being given to state governments.

Essentially, Republicans are claiming that many people lack access to affordable healthcare because federal politicians haven’t been creative enough, and allowing the states to experiment will solve the problem.

But this is abject nonsense. The politics of healthcare reform in America are difficult because powerful actors have a vested interest in an inefficient and inequitable status quo. But the policy question is not difficult. Under a market system, many people cannot afford access to basic medical care, and all but the most affluent cannot afford expensive treatment for a serious illness. To get needy people access to healthcare requires some combination of public expenditure and cross-subsidization of the sick by the healthy. (During his brief “Kimmel” phase, Cassidy understood this.)

Though the ACA did not go far enough, it used tighter regulation and more generous subsidies to provide access to tens of millions of people. Cassidy-Graham would destroy this progress. States are no more likely to find a way to provide effective coverage to more people with less money and fewer rules than they are to discover a formula to convert urine into fine Cabernet Sauvignon. It can’t be done.

Supporters of universal healthcare in California and other states that have used the ACA to cover as many people as possible might be tempted to find a silver lining here. Couldn’t states use the increased flexibility to create a single-payer system? Almost certainly not, because the block grants aren’t generous enough. As Sarah Kliff of Vox observes, states such as California and New York would have to spend a lot more money just to retain the coverage levels of the ACA. The “flexibility” offered by Cassidy-Graham is a ruse — it would make it easy for states to cover fewer people but exceptionally difficult for states to cover more people.

And yet, the federalism fig leaf might be enough to allow this awful proposal to succeed. Arizona’s governor has come out in favor of Cassidy-Graham and McCain, the state’s senior senator, may well follow. Kentucky Sen. Rand Paul is a “no” as of now, but during previous repeal moves his loud public “nos” were converted to quiet “yes” votes. The hard-fought gains of the ACA are at serious risk because of this awful proposal. If you want to defend yourself against the slashers, you might want to consider calling your representatives.

Scott Lemieux is a lecturer in political science at the University of Washington and a regular contributor to the New Republic and the Week

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