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I’m sorry Gentle Readers; we’re here again. If you followed the news, you might have believed that the Graham-Cassidy bill to destroy Medicaid and the Affordable Care Act, ripping health insurance and thus both access to health care and peace of mind from thirty-two million Americans was safely dead. On Friday John McCain announced his opposition to the bill. That gave it two declared no votes (the other from Senator Rand Paul) and two likely no votes (Maine’s Susan Collins and Alaska’s Lisa Murkowski). That should have sunk things, but Rand Paul has voted for prior ACA repeals/Medicaid destruction and has now signaled that he is open to doing so again as long as the cuts are deep enough. Graham-Cassidy didn’t have enough misery in it for him. Without Paul’s no, assuming Collins and Murkowski hold firm, the bill still dies.
The drafters know that and believe they don’t have the votes, so a new version of Graham-Cassidy dropped tonight. You may have heard reports that it gives states more money, but analysts looking at the bill believe that the authors are using accounting tricks to hide that most states still lose badly. The new version guts protection for people with pre-existing conditions, rendering some of them uninsurable at any price and others unable to afford insurance. It still turns Medicaid into a block grant which expires entirely in 2026. It still authorizes states to let insurers sell policies that don’t cover essential health benefits, like prescription drugs or mental health care. Every protection you value in Obamacare is left up to the states to maintain or rescind in Graham-Cassidy 2.0. The only thing they added were partial payoffs for senators who they need to get to fifty votes plus Vice-President Pence’s tie-breaker.
This entire process has been deeply disturbing to me for many reasons. The content of the bill itself, I deem frankly monstrous. Senators voting to pass it are choosing consciously to inflict unimaginable misery on countless people who will be forced off the insurance rolls, forced to buy more expensive insurance, or stuck with insurance that doesn’t cover what they need. It will cost lives. Please don’t take my word for it, listen to the actual experts. Graham, Cassidy, and company will say anything to sell their bill. Here’s a basic summary, quoting one of the people in the know:
- Although the state-by-state numbers being circulated show these states faring well, the Kaiser Family Foundation’s Larry Levitt called them “pretty misleading,” as they don’t take into account the per-person cap on federal Medicaid funding. They also add state savings to the block grants under the bill, but don’t include them in the current law baseline, meaning the comparison isn’t apples to apples.
- Allows “multiple risk pools,” which could separate sick and healthy people and thus drive up premiums for people with pre-existing conditions.
- Allows states to change the federal cap on out-of-pocket costs for enrollees.
- Allows states to decide how much insurers can charge people with pre-existing conditions, the benefits plans must offer and how cost-sharing is structured.
- States only have to describe their plans; they don’t have to submit waivers of insurance rules.
- “If there was any question about Graham-Cassidy’s removal of federal protections for pre-existing conditions, this new draft is quite clear,” Levitt tweeted.
The bottom line is that we all lose. In 2027 every state gets a giant hole knocked in its budget, which they will have to pay for in lives or taxes. Some states might do the right thing, but states often make it very difficult to raise taxes so many will choose the alternative. It’s true that some states lose out sooner, of course. States that tend to vote for Democrats lose the most and fastest:
And more on the accountancy tricks:
The Axios piece and Gaba’s take correspond closely to that of Andy Slavitt, who ran Medicaid for President Obama. Please see this thread for a full version:
I’m sorry to throw so much of Twitter into this post, and also the last, especially for those of you who already follow my feed and so have seen all this before. The content of the bill is itself profoundly disturbing, to say nothing of its effects. But I must rely on Twitter because at the time of writing the new language became available only a few hours ago. The Senate will likely vote to make it law or not on Wednesday. No official estimates of its costs or effects can be in at that time, not even the most basic and incomplete analysis from the Congressional Budget Office. The Senate Parliamentarian, who rules on whether a bill’s provisions are permissible under the special rules the GOP is using to avoid a filibuster, has no hope of parsing through it all honestly and fairly. It took days for independent analysts to get out estimates of the previous draft, which the entire American medical industry from patient groups to doctors to hospitals and insurers, all damned.
This massive overhaul to an industry that constitutes a huge portion of the American economy, written in the dark of night and cynically sold to undecided Senators by promising them their states will not suffer as badly as other states. It was drafted in secret and will be voted on with at most two minutes’ debate in the United States Senate. The Senators have little hope of knowing what they are voting for or what it would do from the CBO, traditionally the most reliable, nonpartisan, and independent authority on a legislation’s costs and effects. The version of Graham-Cassidy which will receive a very partial, tentative score tomorrow that tells us almost nothing about it is the one from last week, not this one. There will be a sham hearing this afternoon.
This is not how a democracy legislates. It may be true on some deeply cynical level that it helps the party I prefer if this thing passes and outrage at the Republican party results in Democratic victories at the polls, but it’s not worth it in lives spent or damage done to our freedom. Legislative process is often arcane and of much aid to those who want nothing accomplished. It badly needs reform. This is not reform. This is highway robbery that might as well have been cooked up in the F Street Mess. If a massively important bill, which is profoundly unpopular in every poll taken for any version of it, can pass this way then we live in a nation where our leaders don’t expect to have to contest fair elections again.
You can say that this is my cause and my party on the defensive. It is. It may be your cause next time. Even if you’re against the idea that the United States should regulate the health insurance industry or help poor people, this should scare the hell out of you. None of the Senators who have votes Graham and Cassidy are now trying to buy voted for the Affordable Care Act. They know that this bill hurts their states and their people. They also know how profoundly undemocratic it is to legislate in secret and sell unpopular bills with lies. One of them chose to vote against a dear friend of his in order to oppose Graham-Cassidy. Take it from John McCain:
I cannot in good conscience vote for the Graham-Cassidy proposal. I believe we could do better working together, Republicans and Democrats, and have not yet really tried. Nor could I support it without knowing how much it will cost, how it will effect insurance premiums, and how many people will be helped or hurt by it. Without a full CBO score, which won’t be available by the end of the month, we won’t have reliable answers to any of those questions.
I take no pleasure in announcing my opposition. Far from it. The bill’s authors are my dear friends, and I think the world of them. I know they are acting consistently with their beliefs and sense of what is best for the country. So am I.
Let me be honest with you, Gentle Readers. I do not, as a person of liberal beliefs, think highly of John McCain on a routine basis. His public statements, positions, and votes often anger me deeply. I’m sure that if he knew of mine, he would feel the same. He suffered terribly in Vietnam, where he went on our behalf. Now he suffers from cancer. I would wish neither on him or anyone else, even for an instant. I hope he has a speedy and full recovery. I also hope that if you dismiss me as a far left crazy who should get back to his history, you don’t dismiss him because we agree on this process being a shame. This is how dictatorships work, with backroom deals cut in defiance of the will of the people and contempt for democratic norms. It should not be how any nation operates, let alone one that declares itself a beacon of freedom.
If you aren’t willing to fight for health care; fight for that. This is a traumatic time for everyone and go-around makes it a little bit worse, but we can’t give up. We have celebrated prematurely too many times, which helped get us here. We can’t stop before the other side, the side that wants to radically transform America, gives up. If we do that, they win and we let it happen. It’s time for Civics 101 all over again: go tell your congressional delegation to vote no. If they have announced opposition, even if they are leaders in the fight against Graham-Cassidy, get in touch to thank and encourage them. We have stopped these bills before through massive public pressure. We can do it again. It just takes enough of us standing up and saying this isn’t right, loudly and often.
Lastly, this week I realized something. You may recall that I greatly admire the writing and ideas of Ta-Nehisi Coates. He makes the point that victory in a struggle for justice is good, but the struggle has value in itself. I don’t think that I, a white man, understood just what he meant until now. We can win this, but we might not. We have a choice before us either way, though. We can stand silent and let bad things happen, at which point we must call ourselves by our right name: accomplice.
Every day we stand up and push back, we make it that much harder for the people who want to do great harm and see injustice thrive to keep on as they would. They want us despairing, convinced of the futility of opposition. This is a bad fight where the odds might be against us. Perhaps we should not dare to hope. We may do better for each other if we assume failure and fight anyway than by succumbing to overconfidence. But we are not alone and we are not powerless. The moral arc of history doesn’t bend on its own, but we can damned well knock a curve toward justice into it. We can do more. We can be a better, more just, more decent nation than we have been. We can hold to the values we claim. We can still be a free people who hope for greatness. No one person is going to change the course of history. Enough of us all pushing can. And have.
Light the phone lines ((202) 224-3121) on fire. Send those ResistBot faxes -they’re still free- every day. Lives and freedom are both at stake. We cannot take anything for granted. This may not be over until 2020 or 2024. We have just got to keep fighting. What we do now, we do for those who come after as much as for ourselves.
And if you disagree with me, Resistbot and those phone numbers work for you too. Every free country, or country that hopes to be free, needs an active, engaged, vigilant citizenry. That goes for all of us and I hope we have become more all those things than we have long been in the course of this. There is value in that struggle. We are all worth fighting for, from the people in Puerto Rico looking at months without electricity and with no relief in sight who should be the sole focus of our attention right now to undecided senators and people with sick children. This is how we can do it.
Thank you for listening again. Once more, there will be history tomorrow.