Logistics, not policy, doom GOP health bill
WASHINGTON — Health insurers, who had been strangely quiet for much of the year, came off the sidelines to criticize it. Many state Medicaid directors could not stomach it, either.
For months now, proposals to repeal and replace the Affordable Care Act have risen and fallen in the House and the Senate, almost always uniting health care providers and patient advocacy groups in opposition but winning support among conservatives, including Republican policymakers. But the version drafted by Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana — and hastily brought into the spotlight last week — went further.
It brought much of the health care world together to stop it, an effort that appears to have succeeded — not for ideological reasons, but for the simple reason that administrators, caregivers, advocates and insurers believed it would not work.
Senate Republican leaders hoped to bring the measure to the Senate floor for a vote this week. But the bill is on life support after Sen. John McCain, the unpredictable Arizona Republican whose dramatic “no” vote killed the previous repeal effort, announced Friday that he could not “in good conscience” vote for the bill. He joined Sen. Rand Paul, R-Ky., in opposition — and Sen. Susan Collins, R-Maine, is leaning hard toward no.
The three would be enough to doom the bill.
“I think Republicans remain pretty trapped between an abstract promise to repeal the Affordable Care Act and the reality of what that would mean,” said Matthew Fiedler, an economist at the Brookings Institution who advised President Barack Obama on health policy. “That basic tension is going to remain.”
Should the Graham-Cassidy measure die, it would almost surely end the long Republican quest to repeal and replace the Affordable Care Act, Obama’s signature domestic achievement. If the Senate does not vote by Sept. 30, the drive to kill the law will lose special protections under Senate rules that allow it to pass with a simple majority, rather than the 60 votes necessary to overcome a filibuster.
The Senate Finance Committee has scheduled a hearing on the measure for Monday, and proponents of the repeal bill say they are not giving up.
In a series of tweets early Saturday, President Donald Trump, who has embraced the legislation in recent days, appeared to be nurturing hopes that the legislative effort could be kept alive. He voiced optimism that Paul would rethink his opposition “for the good of the party.”
At the same time, Trump vented his frustration with McCain, saying he had let his state down and been deceived by Democrats into abandoning a promise.
The drive for repeal of the Affordable Care Act appeared to be dead at the end of July, after McCain’s “no” vote on a “skinny repeal” measure that was designed purely as a vehicle to permit negotiations with the House, which had passed a much more ambitious bill. That measure also had critics who called it unworkable and potentially disastrous for the insurance market, but Republican leaders could argue that they never intended to actually enact it. They were prepared to discard their handiwork as soon as House-Senate negotiations could start. The talks never did. “It is time to move on,” a dejected Sen. Mitch McConnell of Kentucky declared at the time.
But behind the scenes, Graham, whose main expertise is in military affairs, and Cassidy, a gastroenterologist, had already been working with Rick Santorum, a Republican former senator from Pennsylvania, on a measure that morphed into the GrahamCassidy bill.
The bill would require states to organize their own health care systems by 2020 — a time frame that many experts say is unworkable — and would also give states a way to roll back protections for people with pre-existing conditions.
If enacted, the measure would constitute “the largest transfer of financial risk from the federal government to the states in our country’s history,” said the National Association of Medicaid Directors, whose members run the program for more than 70 million Americans.
The legislation would set a cap on how much federal support states would receive per person enrolled in the Medicaid program, while health care costs are rising more quickly than the scheduled growth rate for the cap.
“One of the objectives that Republicans have come to this debate with is to reduce federal spending on health care, and it is very difficult to do that, ultimately, without reducing the people covered,” Fiedler said. “If you’re not making the underlying health care delivery system more efficient, all you’re doing is shifting around the costs.”