The final push has begun. Today, Republican senators Lindsey Graham (S.C.), Bill Cassidy (La.), Dean Heller (Nev.), and Ron Johnson (Wis.) formally announced a new health-care plan; at the end of the month, Congress’s current budget resolution, and with it any serious possibility of repealing Obamacare this year, will expire. In the meantime, the Congressional Budget Office will take its sweet time scoring the legislation, leaving a very narrow window in which to debate, amend, and pass the bill.
Perhaps I should be excited that this is the last health plan standing, however unsteadily. A month and a half ago, when the details remained vague, I wholeheartedly embraced the basic idea that Senator Cassidy has been pushing all year: We should take Obamacare’s funding and simply turn it over to the states. States that like Obamacare can keep it; others can experiment with free-market-based alternatives; still others can use the money to fund ill-advised single-payer escapades. Let a thousand flowers bloom in the laboratories of democracy.
The bill as it’s come together doesn’t really reflect that vision; its priorities are considerably more conservative. It does a whole lot that we right-wingers can love, such as eliminating the individual mandate and putting a “per capita cap” on the entire Medicaid program to control costs. But it has little chance of passing the Senate, where Majority Leader Mitch McConnell has told its sponsors that they will have to cobble together 50 votes from just 52 Republicans on their own. (There is zero chance any Democrat will support the legislation.)
In terms of votes, rather than policy, there are three main problems here.
I wish Graham et al. the best on this, but my hopes are not high.
As a conservative, I don’t much object to this; if blue states won’t raise even a fraction of the money needed to fund Obamacare themselves, they must not really like it that much. (As a fact sheet from Cassidy’s office notes, one way to help make up any shortfall would simply be to reimpose Obamacare’s individual- and employer-mandate penalties.) Red-staters, meanwhile, shouldn’t have to live with a higher level of government health-care spending than they’d enact themselves. But any realist should see the political problem created by cutting states off from large sums of federal cash.
The second problem stems from the way that Medicaid expansion played out under Obamacare and the Supreme Court ruling upholding the law’s constitutionality. Ultimately, it was determined that states were free not to expand the program if they so wished, though going this route would cost them a lot of federal money. Over time, however, the new bill would equalize funding between the states that expanded Medicaid and those that didn’t. Indeed, some non-expansion states would see their total funding increase.
This, too, is fine with me as a conservative, and it’s something the bill’s sponsors touted as a benefit in their press conference today. There’s no good reason to lock in a permanent financial reward for states that went along with our previous president’s desire to reshape American health care. The formula for dividing up the money should rely on states’ demographics as they relate to health, not on their political decisions years ago. But this means many Medicaid-expansion states will lose, and Republican senators from those states will have a reason to oppose the bill.
Finally, after 2026, the bill just . . . stops. If Congress doesn’t take further action by then, the Obamacare money spigot will shut off entirely. Liberals are being dramatic when they pretend this has any chance of actually happening, but it bespeaks a remarkable lack of vision for the bill not to contain even the slightest hint of a long-term plan.
Maybe it’s a political ploy to attract conservatives who want to say they fully repealed Obamacare without losing moderates who know it won’t really happen. But that’s a fine line to walk: Those two groups of politicians would have to employ diametrically opposed arguments in selling the bill to their constituents.
I wish Graham et al. the best on this, but my hopes are not high. The clear route to compromise would have been to meld Obamacare’s funding with conservatives’ love of federalism and free-market approaches to problem-solving. Perhaps that wasn’t really an option, as at the press conference Cassidy said his colleagues across the aisle repeatedly shot him down when he approached them earlier this year. But whatever the reason, this bill is something a bit different, and unlikely to go far.
— Robert VerBruggen is a deputy managing editor of National Review.