The catchphrase underpinning the latest last-ditch Republican push to overhaul Obamacare is “flexibility.”
If the bill passes, the argument goes, states would be freed up to assume greater control of their health care systems, effectively sidelining an inflexible and intrusive federal bureaucracy.
The legislation from Sens. Bill Cassidy and Lindsey Graham would give states more leeway on the subject of pre-existing conditions, something Vice President Mike Pence praised on Thursday. He was asked if he could guarantee that state governors would still require those protections.
“Thomas Jefferson said the government that governs least governs best,” he said. “The question that people ought to ask is who do you think will be more responsive to the health care needs in your community? Your governor and your state legislator or a congressman and a president in a far-off nation’s capital? This is the concept of federalism upon which our Constitution was framed.”
The proposal would also end a raft of Obamacare subsidies and cut off money for the law’s Medicaid expansion program. (There are other, perhaps even more controversial pieces, too: read here for the details.)
The federal money won’t disappear entirely, though. It would be repurposed, at least in part, to fund a block grant program — meaning the states would receive lump sums of cash. How precisely they would use it is and will likely remain for some time an open question.
And that’s where things could get really weird.
The bill would effectively devolve the broad questions the federal government has been wrestling with — like how to keep people in the market without a mandate and whether those with pre-exisiting conditions should be guaranteed coverage — to officials at the state level.
How they choose to spend the block grant cash, which will come with limited conditions and requirements, could yield 50 different health care programs for each of the 50 states.
Republicans know this. And at least one has a very specific concern.
Louisiana Sen. John Kennedy is pushing now to add a provision to the bill that would ban states from using this new federal grant money to help fund single-payer initiatives.
“I don’t think states should have the authority to take money from the American taxpayer and set up a single-payer system,” Kennedy told the Washington Examiner earlier this week. “Some people think that’s inconsistent with the idea of flexibility, but that’s what the United States Congress is for. I very much believe in flexibility, and I know governors want flexibility, but it’s our job to make sure that money is properly spent.”
A spokeswoman for Kennedy would only say the senator “is still finalizing his amendments” and that more detailed plans could come next week.
Still, Graham seemed to dismiss the prospect of such a tweak outright when asked about it Tuesday.
“You know federalism can’t be on your terms,” he told Business Insider. “If California wants to go to single-payer health care plan, let them knock themselves out. I’m not here to tell people what’s best for them, I’m here to give them a chance to decide other than somebody in this town.”
This underlying question here is not a new one. Back in March, in the midst of the first GOP repeal bid, California State Sen. Ricardo Lara told CNN, “There’s no doubt that (President Donald Trump’s) election and what Republicans are doing to dismantle health care has really given us an opportunity to have an honest dialogue about how we get to health for all.”
Lara’s statewide single payer bill, currently held up in the California assembly, would likely require the repurposing of federal funds. It is still unclear if Graham-Cassidy’s increased “flexibility” would, by the letter of the law, make that any easier.
On a political level, it almost surely would.
Chuck Idelson of the National Nurses United union, which has defended the ACA while also pushing hard to promote Sen. Bernie Sanders’ “Medicare for all” plan, said the Republican bill — which NNU strictly opposes — would “obviously increase the urgency for there to be some immediate action to protect all the people that would be harmed by (Graham-Cassidy).”
But that’s California. The political economy in deep red states, and anywhere else federal Medicaid expansion funds were turned down, is obviously quite different.
Graham-Cassidy would redirect a significant sum of federal aid in that direction. The effect, though, is hard to project. The money would come with fewer strings attached than under Obamacare and would be spent in a market expected to be less thoroughly regulated than it is now.
Republicans and Democrats in those states would likely find themselves in pitched debate — not unlike we’ve seen on the federal level — over how to use the grant money. (And those, it should be noted, would only be authorized through 2026.)
The GOP plan would also place a greater strain on state coffers. The responses would differ, at least in part, from one capitol to another. The federal umbrella would be severely compromised and crossing the border from Kentucky to Virginia would, even more so than now, likely mean switching over between two entirely different health care systems.
The irony staring Capitol Hill in the face now is that, while this bill could end one battle (at least in Washington), it seems primed to open up 50 new ones, in all 50 states.