Like prior versions, the latest version of the bill from Senators Bill Cassidy and Lindsey Graham to repeal and replace the Affordable Care Act (ACA) would cut federal funding for health coverage for the large majority of states over the next decade (see Table 1). And the cuts would grow dramatically in 2027, when the bill’s temporary block grant (which would replace the ACA’s Medicaid expansion and marketplace subsidies) would expire and its Medicaid per capita cap cuts would become increasingly severe. We estimate that in 2027 alone, the bill would cut federal health care funding by $298 billion relative to current law (see Figure 1), with the cuts affecting all states.
In fact, starting in 2027, Cassidy-Graham would likely be even more damaging than a straight repeal-without-replace bill because it would add large cuts to the rest of Medicaid — on top of eliminating the Medicaid expansion — by imposing a per capita cap on the entire program. The Congressional Budget Office (CBO) has previously estimated that the repeal-without-replace approach would ultimately leave 32 million more people uninsured.[1] Cassidy-Graham would presumably result in even deeper coverage losses than that in the second decade as the cuts due to the Medicaid per capita cap continue to deepen.
- Eliminate the ACA’s Medicaid expansion and ACA’s marketplace subsidies in 2020 and replace them with an inadequate block grant. Under our estimates, the block grant would provide about $239 billion less between 2020 and 2026 than projected federal spending for the Medicaid expansion and marketplace subsidies under current law, with the cut reaching $40 billion (16 percent) in 2026. The block grant would not adjust based on changes in states’ funding needs, and it could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance. And, as noted, the block grant would disappear altogether in 2027.
- The enormous cut in 2027 reflects two factors. First, the block grant would disappear in 2027. The bill’s sponsors have claimed that the rules that govern the budget reconciliation process, which allows the bill to pass the Senate with only 50 votes, necessitated that the proposed block grant be temporary. In reality, however, nothing in those rules prevents the bill from permanently funding its block grant. Furthermore, the expiration of the temporary block grant would create a funding cliff that Congress likely couldn’t afford to fill. Even if there were significant political support for extending the inadequate block grant in the future, budget rules would very likely require offsets for the hundreds of billions of dollars in increased federal spending needed for each additional year.[3]
The GOP health-care bill shows the need for regular order.
Kennedy was the showy performer in that ugly spectacle, but Senator Biden, as chairman of the Judiciary Committee, was the stage director. Prior to Bork’s nomination, Biden had in fact said that he would support it: Bork was, after all, a distinguished legal scholar with a long history in public service. Bork had many challenges in front of him: For one thing, he was very sharp-elbowed in intellectual disputes, which had not won him very many friends.
.. The Senate majority leader at the time was Democrat Robert Byrd, a man who had rejoiced in the title of Exalted Cyclops of the Ku Klux Klan, and who held a grudge against Bork for his role in the Watergate scandal, during which Bork had fired special investigator Archibald Cox on the orders of President Richard Nixon.
.. The Senate majority leader at the time was Democrat Robert Byrd, a man who had rejoiced in the title of Exalted Cyclops of the Ku Klux Klan, and who held a grudge against Bork for his role in the Watergate scandal, during which Bork had fired special investigator Archibald Cox on the orders of President Richard Nixon.
.. The Democratic primary field was very full: There was Biden
.. Biden could not afford to stand by his earlier assessment of Bork and announced his opposition to the nomination shortly after it was made formal.
.. The 14 hours Senator Byrd had spent filibustering the Civil Rights Act of 1964 did not prevent him from becoming the Democratic leader in the Senate.
.. The Bork nomination, on the other hand, was an ordinary piece of government business elevated by Democrats to the status of national emergency in the service of narrow partisan interests. Biden was running for president, Kennedy was running for conscience of the Democratic party, and Byrd, frustrated by Republicans’ lack of cooperation on a number of his spending priorities, had promised: “They’re going to pay. I’m going to hit them where it hurts.”
.. The hysteria and vitriol directed at Bork were of a sort rarely seen since the early 19th century. But they quickly became commonplace.
.. But the rules of the game are not all there is to the game. What in another context might be called “sportsmanship” is in politics a question of prudence and even of patriotism, forgoing the pursuit of every petty partisan advantage made possible
.. The progress from Robert Bork to Merrick Garland is a fairly obvious story, but there is more to it than that:
- The increasing reliance upon legislative gimmicks such as omnibus spending bills and retrofitting legislation to fit with the budget reconciliation process,
- the substitution of executive orders and open-ended regulatory portfolios (“the secretary shall . . . ”),
- the prominence of emergency “special sessions” in the state legislatures,
- the absence of regular order in the legislative and appropriations process —
all are part of the same destructive tendency. Procedural maximalism in effect turns the legislative system against itself, substituting the exception for the rule and treating every ordinary item of business as a potential emergency item.
.. at the time, their numbers in the Senate were enough to secure their victory without a filibuster. But the course they set in those hearings — one of maximal confrontation, of reaching for whatever procedural cudgel is close at hand — led directly to our current state of governmental dysfunction.
.. at the time, their numbers in the Senate were enough to secure their victory without a filibuster. But the course they set in those hearings — one of maximal confrontation, of reaching for whatever procedural cudgel is close at hand — led directly to our current state of governmental dysfunction.
.. The recently proffered Republican health-care bill instantiates much of what is wrong with our politics:
The bill was constructed through an extraordinary process in which there were
- no hearings,
- no review from the Congressional Budget Office, and
- no final text of the legislation until shortly before the vote.
- The process is erratic and covert rather than regular and transparent.
- It was put together in a purposeful way to avoid substantive debate and meaningful public discourse,
making the most of the majority’s procedural advantages for purely political ends.
.. As Rod Dreher recently put it, Republicans will have to choose whether they love the rule of law more than they hate the Left.
.. Republican populists who argue that the GOP must play by the same rules in the name of “winning” have very little understanding of what already has been lost and of what we as a nation stand to lose.
The United States will not thrive, economically or otherwise, in a state of permanent emergency.
.. What’s truly remarkable about our current constant national state of emergency is that no one can say exactly what the emergency is. But we all seem to be very sure that something has to be done about it right now, that we must rouse ourselves to excitement about it, and that the ordinary rules of lawmaking and governance no longer apply.
There is not much political mileage to be had from arguing for regular order, transparency, and procedural predictability — but that’s part of what makes those things so valuable. Order in the little things is a necessary precondition of order in the big things. Orderly government cannot be built on a foundation of procedural chaos.
Democrats to Use Senate Rules to Challenge Health Care Bill
Democrats are preparing to challenge these provisions, among others:
Planned Parenthood: The Senate Republican bill would cut off federal Medicaid funds for Planned Parenthood for one year.
Age ratios: The Senate bill would let insurers charge older consumers five times as much as young adults. Under the Affordable Care Act, they can charge no more than three times as much. Democrats say the purpose of the change is purely regulatory, not budgetary
Waiting period: People who went without insurance for approximately two months in the prior year would be required to wait six months before they could start coverage under the Senate bill. Democrats say the purpose is not to save money, but to regulate insurance and to encourage people to obtain coverage without imposing an “individual mandate.”
.. Democrats are also expected to challenge a provision of Mr. McConnell’s bill that would allow states to impose work requirements on some Medicaid beneficiaries.. And they are prepared to challenge a proposal by Senator Ted Cruz, Republican of Texas, that would allow insurers to sell stripped-down insurance, free of most federal regulations, if they also offered at least one plan that complied with insurance standards like those in the Affordable Care Act. Health plans could, for example, omit coverage of maternity care or mental health care.
It’s Time Republicans Abandoned the AHCA
reconciliation allows the GOP to further undermine the stability of the ACA’s insurance market, but not to remedy its fundamental structural flaws.
.. Instead of straining with reconciliation to patch the fissures in the insurance market, the GOP should employ the regulatory powers of the Department of Health and Human Services to fix it. By repealing an October 2016 regulation that was used to prevent the sale of actuarially priced “short-term” insurance, Secretary Tom Price could reestablish a market in which health insurance is competitively priced in proportion to most individuals’ health-care needs. This would relieve the exchanges and their subsidies of much of the burden placed on them, repurposing them as a targeted safety net for the chronically ill.