The Washington PostDemocracy Dies in Darkness

Obamacare repeal isn’t really dead

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Against all odds, Republicans keep coming up with worse and worse health-care plans.

To be fair, though, it's not entirely clear that we should even really call them that. Each of them has been more like a plan to have a plan—or, it's hard to tell, maybe a plan to have a plan to have a plan—than an actual one. Indeed, House Republicans passed a health-care bill that President Trump himself thought was "mean" out of the expectation that the Senate would make it better. It didn't. Instead, the Senate came within a vote of approving a bill that one of its supporters Senator Lindsey Graham (R-SC) called a "fraud" and a "disaster" in hopes that a conference committee with the House would yield something a little less "terrible."

Their latest one, co-sponsored by Graham and Senator Bill Cassidy (R-LA), was no different. Well, except for the fact that it would have stopped pretending that the rest of Congress could improve what even its supporters conceded was a flawed plan—"I could maybe give you 10 reasons why this bill shouldn't be considered," Senator Chuck Grassley (R-IA) said, despite endorsing it—and started pretending that state governments could implement it in a way that, through the magic of federalism, would supposedly deliver better care for less money. In this case, it allegedly would have done so first by eliminating all of Obamacare's spending, then cutting Medicaid even further than that, and finally sending some of this money back to the states as a shrinking block grant for them to set up with their own health-care systems with—systems where the sick could once again be discriminated against. Republicans, in other words, were trying to give governors a new problem to deal with, and calling it a solution.

Now, in spite of the fact that Graham-Cassidy won't even get a vote anymore, it could still end up being the template for future Republican attempts to repeal Obamacare. (No, they're not going to stop trying). The reason is that it allows them to avoid a lot of the hard choices inherent to health-care by cloaking themselves in the ideologically-soothing garb of federalism. "Who do you think will be more responsive to the health-care needs of your community," Vice President Mike Pence asked, "your governor and your state legislature, or a congressman and a president in a far-off nation's capital?"

Well, the answer to that is pretty obvious if you live in Texas or Tennessee or Florida. It's the people in the far-off nation's capital. That's because all those states refused to accept the mostly-free money the federal government has been offering them to expand their Medicaid programs. So did Alabama, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Utah, Virginia, Wisconsin, and Wyoming. Hurting President Obama's legacy sure seems more important to a lot of red states than helping their poorer constituents does.

The idea that delegating more health-care decisions to them would be a good thing is one of the worst things Republicans have come up with. Think about it like this. Graham-Cassidy not only would have cut health-care spending overall, but it also would have redistributed the remaining money from states that did expand Medicaid to ones that didn't. The nonpartisan Kaiser Family Foundation estimates that the expansion states would have lost something like $180 billion over the next 10 years, while the non-expansion ones would have gained $73 billion. Now what do you think they would have done with that money? Probably not cover sick and poor people. They already decided not to do that when they were given the chance. Instead, they might have used it to ... cut taxes? Actually, yes. As Matthew Fiedler and Loren Adler of the Brookings Institution point out, Republicans would have freed states to use this money for a lot of things they're already doing. So instead of paying for, say, their mental health and substance abuse programs out of their own pocket, they could have used this new money to do so—allowing them to get rid of the taxes they'd been using to cover the cost before.

This shouldn't be too surprising. All Republican roads, after all, lead to tax cuts. But it is a reminder that freedom for states can often conflict with freedom for individuals. Being charged more if you're sick isn't the liberty most of us have in mind. But it is the type that Republicans do when they talk about letting local politicians make health-care decisions. Senator John Kennedy (R-LA), for one, only wanted to empower states as long as they didn't try to set up their own government-run health-care systems. Republicans want federalism as a cover for their own policies, not Democratic ones.

This might all be moot for now, but it won't be for long. The Trump administration is already stepping up its efforts to undermine Obamacare's health insurance markets. Which is to say that maybe not today, maybe not tomorrow, but soon, and for the rest of their lives, Republicans are going to try to get rid of Obamacare again. They'll say that their sabotage proves the law doesn't work. And that the only solution is to let states do the unpopular things that Republicans don't want to run on anymore.

Federalism, ain't it grand.