—Eliminate the [Affordable Care Act’s] marketplace subsidies and enhanced matching rate for the Medicaid expansion and replace them with an inadequate block grant. [JB: I’ve often commented about block grants in the context of the Republicans’ push to do the same thing to SNAP (nutritional support). It’s a budget cut disguised as state flexibility.] Block grant funding would be well below current law federal funding for coverage, would not adjust based on need, would disappear altogether after 2026, and could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance.
JB: A basic selling point of the Cassidy-Graham bill is the old saw, “Let’s turn health care over to the states, as they know their needs better than faceless D.C. bureaucrats.” Because, you know, bureaucrats in Albany and Topeka and Harrisburg all have lovely faces. In fact, it’s just an opaque way to do what all the other Republican proposals have done: shrink the program’s benefits, coverage and costs. Which, not incidentally, paves the way for bigger tax cuts for their donor base.
—Convert Medicaid’s current federal-state financial partnership to a per capita cap, which would cap and cut federal Medicaid per-beneficiary funding for seniors, people with disabilities, and families with children.
JB: Along with reversing the coverage gains — 11 million low-income adults — under the ACA’s Medicaid expansion, this will work much like a block grant on the existing Medicaid program and is thus a surefire way to undermine this vital support for vulnerable families.
—Eliminate or weaken protections for people with preexisting conditions by allowing states to waive the ACA’s prohibition against charging higher premiums based on health status and the requirement that insurers cover essential health benefits including mental health, substance abuse treatment, and maternity care.
JB: More devolution to the states. But health care is something that clearly benefits from both national standards and national risk pooling.
—Destabilize the individual insurance market in the short run — by eliminating the ACA’s federal subsidies to purchase individual market coverage and eliminating the ACA’s individual mandate to have insurance or pay a penalty — and risk collapse of the individual market in the long run.
JB: Consider this, from the Congressional Budget Office the other day: “[We] expect the nongroup health insurance market to be stable in most areas of the country. Preliminary data for 2018 show that insurers will offer coverage in all or almost all areas. Although premiums have been increasing, most subsidized enrollees buying health insurance through the marketplaces are insulated from those increases because their out-of-pocket payments for premiums are based on a percentage of their income; the federal government pays the difference between that percentage and the premium for a benchmark plan.”
In other words, as I argued recently, it took a few years, but private insurers are figuring out how to calibrate prices under the ACA and, because of the way the law works, most of their customers remain somewhat protected from shocks to their health costs. This is critical progress that Cassidy-Graham would unwind.
—Eventually result in larger coverage losses than under proposals to repeal ACA’s major coverage provisions without replacement. The Congressional Budget Office (CBO) has previously estimated that repeal-without-replace would cause 32 million people to lose coverage. The Cassidy-Graham bill would likely lead to greater numbers of uninsured after 2026, however, because it would not only entirely eliminate its block grant funding — effectively repealing the ACA’s major coverage expansions — but also make increasingly severe federal funding cuts to the rest of the Medicaid program (outside of the expansion) under its per capita cap.
JB: Not to bury the lead, but this last bit is the kicker, especially politically. I yield to no one in my cynicism regarding conservative health-care politics, but the fact that this vote is apparently close is breathtakingly revealing of their total disdain for doing their jobs. Prior bills died in the Senate — granted, ultimately by just one vote — because a few Republicans thought that maybe their constituents didn’t send them to D.C. and pay them lavish salaries so that they could take health coverage away from middle and low-income people.
Nothing’s changed since then, except in this case, there’s not yet a CBO score of the coverage losses, so they can hide behind their supposed ignorance of the bill’s effects. However, the logic of the CBPP “scorers,” as stated above, is simple, clear and obvious. As with every other bill of this ilk we’ve seen, when you cut spending, coverage and benefit provisions, the results are always the same: Tens of millions lose coverage.
CBO has said it will take a few weeks to get out the score, but they also said they’d deliver a rough fiscal accounting next week. If all they show is that the spending cuts will lower the deficit (compared to a future with an intact ACA) and say nothing about coverage losses, they will be doing an uncharacteristic disservice to a debate they’ve heretofore kept far more rational than it would have been without their input. Please, CBO: Do not give Cassidy-Graham credit for spending reductions without showing the impact of those reductions.
Suppose I sat down with my wife and told her I’ve run the spreadsheets and figured out how we can save thousands of dollars per year: Stop buying groceries! “But we’d starve,” she’d reply (she’s very common-sensical). “Well, perhaps,” I’d reply, “but I haven’t run that part of the analysis yet.”
I don’t have a great feel for the politics of where this is going, but I’m sure that any complacency would be dangerously mistaken. You simply can’t overestimate the extent to which the Republican members will sell out their own states and their own constituents to kill a program named after the last president while paving the way for bigger tax cuts, even as said program is actively delivering affordable health coverage to tens of millions of Americans.