One short week ago, 16 Senate Democrats and dozens of progressive groups rallied with Sen. Bernie Sanders (I-Vt.) to celebrate the release of his Universal Medicare for All bill — a moonshot that they hoped would reset the national conversation on health care.
Sen. Lindsey O. Graham (R-S.C.) sounded downright giddy. His own legislation to curtail the Affordable Care Act, and block grant Medicaid, was released just a few hours before Sanders’s, to a smaller but just as skeptical group of reporters.
“You’re skipping Bernie for this?” he joked. Before he got to the substance of the Cassidy-Graham bill, the senator framed it as an alternative to the Sanders bill, a way to stop an inevitable lurch toward European-style universal coverage: “Hell no to Berniecare!”
The momentum for Graham’s bill, and the surprise reanimation of a repeal effort that has been declared dead twice before, has sparked one of the Capitol’s most cherished traditions: panicky Democrats taking shots at each other. Egged on by Graham, and by a snarky Republican National Committee, a few liberal analysts and Democratic pols have asked whether Sanders bears some responsibility for the 11th hour repeal fight.
“I thought that anyone who believed that you should take your eye off the ball before Sept. 30 wasn’t being smart,” Sen. Heidi Heitkamp (D-N.D.), one of 30 Democrats who did not endorse the Sanders bill, told Politico.
Sanders, who since his presidential bid has become judicious about talking to reporters in Senate hallways, was particularly tight-lipped at Tuesday’s lunches, saying only that single-payer was “where the American people want to go.” He had, after all, delayed the release of his bill several times, partially to get more input from Democrats, but largely to avoid confusing the Democratic caucus’s united stance against repeal.
But did he crack the door open for Republicans this time? Most of his colleagues say no; those who don’t reject the idea outright acknowledge that the GOP was never going to let the Sept. 30 reconciliation deadline pass without another run at health care. One pointed out that the Sept. 30 deadline itself came after Sanders, the ranking member of the Senate Budget committee, got the Senate parliamentarian to clarify that Republicans could not drag the issue out forever — a development that Democrats considered to be a win.
“As soon as the parliamentarian’s ruling came down, they were going to do something,” said Sen. Chris Murphy (D-Conn.).
Sen. Bill Cassidy (R-La.), the bill’s co-sponsor, had been talking up Medicaid reform since the 2016 election; Graham himself had been workshopping the bill since before the collapse of the Better Care Reconciliation Act, the first Senate vehicle for repeal, and had pledged to release it in September before Sanders set a date for his Medicare for All launch.
More baffling to Democrats was Graham’s Sanders-focused selling point: That if his bill passed, a federal Medicare for All program would become impossible. By block-granting Medicaid, Republicans would prevent Democrats from going back to the well when they next controlled Congress, because states would have set up their own insurance systems.
“Bernie, this ends your dream,” Graham said last week.
That, say Democrats and policy analysts, made sense to Republican senators but almost no one else. The block-grant proposal at the center of Cassidy-Graham is astoundingly unpopular, with just 26 percent of all voters and 48 percent of Republicans telling pollsters that they favor it. In an essay for Slate, the conservative writer Reihan Salam warned that Republicans, if they passed the bill, would be shifting voter blame for rising health-care costs or lost coverage onto state legislatures, at a moment when Republicans enjoy historic control of the states.
[T]he complaints they could once deflect to Congress would land firmly on their doorsteps. Every single person employed in the health care sector and every single person who depends on subsidized medical care, whether directly or indirectly, would have a vested interest in ensuring that local health systems are generously funded and that funding grows robustly from year to year. They would soon learn that their livelihoods depend on the outcome of state legislative races, and they would vote accordingly. All of this is perfectly consistent with the conservative commitment to decentralizing health care policy. It is also perfectly consistent with Republicans losing elections.
If Cassidy-Graham became law, and became unpopular, Graham’s push would have enabled Sanders in a more effective way. The two senators, joined by 48 Republicans and the vice president, will have dramatically altered a major entitlement in a two-week sprint, with no serious CBO score, no bipartisan input, and one hasty hearing. To describe why that mattered, one Democratic aide pointed to an analysis from New York magazine’s Jonathan Chait, a liberal columnist who had ridiculed the Sanders bill.
It would make it easier for the left to argue that the program’s compromise structure is a failure, that its markets are inherently susceptible to sabotage by Republican administrations, and that the risk of political capital is worthwhile. And the method used to pass repeal — a hastily assembled reconciliation bill devoid of serious analysis — would make fools of the party’s Senate institutionalists. Democrats would be incentivized to pass a sweeping 50-vote Medicare expansion, with the goal of creating as many beneficiaries as possible, as quickly as possible.
After the near-passage of BCRA, some progressive policy analysts began daydreaming about how the 50-vote threshold could advance their goals — goals that had been stymied when the Democrats of 2009-2010 passed most of the ACA through the normal legislative process. Mike Konczal, an analyst at the Roosevelt Institute, posited a way to pass outright Medicare for All, and a fallback plan of Medicare for More. The key, in both cases, was that progressives’ simplest ask — a public option — could pass easily.
The CBO will analyze the proposal and basically say “Congratulations, you have $16 billion a year from your savings to spend, for free. What would you like to spend it on?” The CBO has scored an aggressive public option as savings money and done so consistently, on the order of $158 billion over ten years. It does this by lowering premiums overall, which means the ACA spends less on subsidies. But it also means more employers take advantage of it and pay people less through tax-free benefits, which increases the amount taxes collected. Combine it with some other easy budgetary reforms to pass through reconciliation, like having Medicare negotiate lower drug prices, which alone would save about $11 billion a year, and we can picture an overall savings of $30 billion a year.
At the time, Konczal, like most of Washington, assumed that the GOP had made its final, failed lunge at repeal. (One Democratic aide pointed out, ruefully, that the Sunday talk shows after the release of both Cassidy-Graham and Medicare for All asked no questions to legislators about the Republican bill.) Some observers, making the point that the 50-vote standard would actually make progressive health-care reform dramatically easier, have been chastised for sounding glib about how block-granting and the rest of Cassidy-Graham would affect health care in the years before Democrats could reverse it.
If they sounded that way, it was because the thought of beating back repeal in March, May, and July, and losing in the final hours before the deadline, was unthinkable to Democrats. In an interview last week, shortly before his rollout event, Sanders shook his head when asked if Republicans could take a final, successful run at repeal.
“It is like a zombie,” he said.