The latest iteration of a Republican anti-Obamacare bill is being bandied about the Senate GOP caucus. The dirty not-so-secret is that, in significant ways, it isn't Obamacare repeal so much as Obamacare reform. But in other significant ways, it could be better than the previous repeal efforts Congress has tried this year.
The bill, known as Graham-Cassidy and sponsored by Sen. Lindsey Graham of South Carolina, Bill Cassidy of Louisiana, Dean Heller of Nevada and Ron Johnson of Wisconsin, repeals certain aspects of Obamacare but leaves others in place . Gone: the individual and employer mandates, as well as some of the taxes (including those on medical devices, health savings accounts and Medicaid providers). The Medicaid expansion would effectively end in 2020, although the amount of federal funding devoted to the program would continue to grow between now and then, and afterward as well -- on both aggregate and per capita bases.
Remaining in place, aside from most of the spending, are most of the taxes and many of the regulations (at least until HHS Secretary Tom Price can change those regs through the normal process). If you want the federal government out of health care, or even back to the level of intervention that existed before Obamacare, you are going to be sorely disappointed.
One unfortunate truth revealed during the current debate , however, is that there is not much political will for returning to that status quo ante. The scare-mongering about projected coverage losses, exaggerated though they were , worked. (You'll no doubt hear more scare-mongering about coverage losses from this bill, as you would about any GOP health bill -- even though we know the earlier estimates were fatally flawed, even though the Congressional Budget Office hasn't scored this bill yet, and even though scoring a bill that shifts much decision-making authority to the states would be virtually impossible given the many different and unpredictable ways they would implement it.) And as we discussed yesterday , most Americans are content to let Uncle Sam continue to pile up the debt. The fact that the GOP is reduced to considering a bill like Graham-Cassidy reflects these realities.
That said, all is not lost. The bill would enhance HSAs, allowing Americans to put more money into them and use them to pay insurance premiums or direct primary care. That's a big win for those who want to see us move away over time from so much reliance on third-party payers. The bill also includes the so-called Cruz amendment, which would allow insurers to offer catastrophic-only plans that cover less but at a lower cost, if they offer other plans compliant with all of Obamacare's coverage mandates. That should help put downward pressure on premiums, although it'll be less effective without substantial changes to high-risk pools. If we are going to subsidize patients with expensive health conditions, we need to do it in a way that doesn't drive up premiums for others and lead to the kind of death spiral Obamacare is beginning to experience in the individual market.
The biggest plus here, though, is the way it shifts most of the decision-making for health care down to the states.
This is good from a philosophical standpoint -- in general, we get better decisions when they're made closer to those they affect. But the entire Obamacare and now Obamacare-repeal debates have illustrated why it's good from a practical standpoint.
In short, a nation of more than 320 million people (and growing) is unlikely, and increasingly less likely, to agree on broad policies for such an important issue as health care. There is never going to be an approach to something as complex and personal as health care that is welcomed equally in New York as it is in Texas, in Georgia as it is in California. Our size and societal diversity are oft-neglected reasons we don't have the same, universal approach to health care seen in smaller industrialized countries, such as those in Europe. We don't have the same kind of social consensus that exists in those countries -- and certainly not the kind of consensus that existed when most of those systems were created, in the mid-20th century. Heck, we don't even have the same kind of social consensus many Americans knew earlier in their lives . Trying to force a policy solution on this entire country, in the glaring absence of that kind of consensus, simply isn't going to work, whether it's the kind Ted Cruz would favor or the kind Bernie Sanders would cook up. We will end up fighting this fight forever.
So stop trying to do it. Let California proceed as it wishes, and give the same latitude to Texas. But if they run up the red ink, or if their people suffer, don't bail them out. Let their voters choose leaders who will fix whatever problems they create.
In doing that, the federal government ought not to favor one approach over another from a fiscal standpoint. Yet that's exactly what we have had in past decades through Medicaid. A spreadsheet by the authors of Graham-Cassidy shows that, while Medicaid's average spending per beneficiary was $2,684 in 2016, it ranged from $373 in Mississippi to $10,242 in Massachusetts (Georgia's was $823). Some of this reflects the higher match rate for those included in Obamacare's Medicaid expansion, but it also owes to the way high-spending states have milked Medicaid for money on non-expansion enrollees.
Graham-Cassidy would level the playing field, increasing spending per beneficiary to $4,419 by 2026 but narrowing the range: from $4,372 in Wyoming to $4,418 in California (Georgia's would be $4,417; there's also a uniquely large jump to $6,495 in Alaska, for reasons I don't understand unless it's just a blatant attempt to get Sen. Lisa Murkowski to vote for it).
What's not clear to me is how much freedom states would have to adjust the number of people they cover with that money. Done right, the result ought to be more motivation for higher-spending states to seek efficiencies, while lower-spending states cover more people.
And that's where the onus ought to be. States should have the flexibility to cover their populations in the ways that make sense for them, while facing the pressure to lower health costs per person.
If that works, other reforms might be possible in the future. Congress has to re-learn the art of taking what it can get today, and then try for more tomorrow. As things stand, this looks like the best chance for now to begin cleaning up the mess Obamacare has made.