Senate Republicans face a major, major political problem. I get that. They have embraced the repeal and replacement of Obamacare as a moral crusade, as the animating goal of their party and their movement, and now that they have control of the entire Washington establishment, they have proved themselves spectacularly incapable of pulling it off.
As a result, the Graham-Cassidy bill, scheduled for a vote next week, is "the last stage coach leaving Dodge City" for Republicans, as Sen. Pat Roberts of Kansas described it. Like Roberts, most Senate Republicans don't really try to defend the bill in policy terms, because they can't. It's a purely political vehicle, cobbled together out of bits and pieces of previous failed efforts in order to try to solve a political problem.
But here's the thing: This purely political vehicle has a very real chance of becoming actual law. If it passes the Senate, it will have significant partisan momentum behind it, and House Speaker Paul Ryan has already announced that he intends to put it on the floor for a straight up-or-down vote. If the House passes it as well, it will be sent to the desk of President Trump, who will sign it faster than you can say "Rocket Man."
If you're a Republican politician with any semblance of responsibility or commitment to public service -- I'm looking right at you, Johnny Isakson -- that reality has to give you serious pause. This is not some show vote; there is no safety net this time, and there are no takebacks. If you cast a vote in the affirmative next week in hopes of saving your party some political embarrassment, and this subsequently becomes law, what are you going to say later when you look in the mirror?
Are you going to congratulate yourself for having passed a carefully thought-through, well-vetted piece of legislation that is quite literally a matter of life or death for your constituents? Or will you look back in shame, wondering what on earth you have done for the political equivalent of 30 pieces of silver?
Because make no mistake, this would be a disaster for health-care policy in this country, for tens of millions of Americans who will lose coverage, for tens of millions more with pre-existing conditions and in the long term for the Republican Party as well. Insurers hate the bill; hospitals hate the bill; voters hate the bill; doctors hate the bill; patient advocacy groups hate the bill, rural health-care providers hate the bill. All of those groups have competing interests; getting them to agree, unanimously, on any major aspect of health-care policy would ordinarily be difficult. Yet on this bill, they are united in opposition.
"We believe the Graham-Cassidy amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care,” as the president of the American Medical Association put it, warning that it will also undermine protections for those with pre-existing conditions.
In a recent interview with Denis O'Hayer of WABE, Isakson disputes the claim that the bill would expose those with pre-existing conditions to much higher, even unaffordable premiums. But again, just about everybody outside the Republican Party -- from insurers to doctors to hospitals to health-care experts -- say that such assurances are false.
In a letter sent this week to Senate leaders, the National Association of Medicaid Directors, representing Medicaid officials in all 50 states, also pointed out the damage that such a hastily drafted and poorly vetted piece of legislation would do, warning that the promised flexibility in Medicaid doesn't begin to compensate for its spending cuts.
"Taken together, the per-capita caps and the envisioned block grant would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history," they write, warning that most states are totally unprepared to make that transition in the unrealistic time frame permitted:
"The scope of this work, and the resources required to support state planning and implementation activities, cannot be overstated. States will need to develop overall strategies, invest in infrastructure development, systems changes, provider and managed-care-plan contracting, and perform a host of other activities," they point out. "The vast majority of states will not be able to do so within the two-year time frame envisioned here, especially considering the apparent lack of federal funding in the bill to support these critical activities."
That's the kind of basic problem that would be identified and fixed through a normal committee process. But that process didn't happen in the Senate, and it's not going to happen in the House either. As a result, the Graham-Cassidy bill is riddled with such unresolved issues. As the state Medicaid directors also point out, the bill "would not even have a full CBO score until after its scheduled passage, which should be the bare minimum required for beginning consideration."
Read that again, because it's important: A CBO score should be the bare minimum before you even begin to consider such a bill, yet Republicans are rushing to complete enactment before such a score can be delivered.
Republican rhetoric holds that we should devolve Medicaid responsibility back to the 50 states, because they supposedly know the issues best. Yet here we have the very people who are running those state programs, begging Congress not to make such major changes in such a slapdash manner, and their strongly worded advice is being ignored.
It's being ignored because the last stagecoach is leaving Dodge City, and Republicans don't really give a damn where it's headed.