What a difference a week makes.
Last week, many commentators (including me) saw the Graham-Cassidy bill as a bit of Hail Mary legislating, a last desperate stand against Obamacare. This week, it started to look as if it might actually have some chance of passage. The legislative math remains daunting; the parliamentary obstacles high. But the status of Republican health care efforts has moved from “flatline” to “still breathing, barely.”
The situation is so fluid that I don’t want to make predictions, other than to say that the chances of passage are still south of 50 percent. But as long as it’s a live possibility, we have to think about what passage might mean. I think that one of the most interesting, and least explored, questions is what our health care politics would look like if this thing managed to pass.
Why is that an interesting question? Because before 2008, we barely even had anything that people in other Western democracies would recognize as health care politics. In most such countries, the health minister is one of the most important government jobs — far more important, in many places, than heading a tiny and toothless defense ministry. And debates over the national health care program, whatever its design, are major issues in election after election.
In the U.S., before 2008, Democrats would complain about the cost of our health care spending, and then perform ritual obeisance to some never-never national health care program. Republicans would largely ignore the issue while mouthing the words “block grants” — code for taking money and power from the federal government and giving it to states via discretion over Medicaid. No one would talk much about all the spending we were already doing on programs like Medicare, Medicaid and the VA. Every four elections or so, Democrats might get close to some sort of national health care scheme, but they always found that in the end, while voters might like the idea of guaranteed health care, they sure didn’t like the taxes needed to pay for it, or the changes that would have to be made in their own very satisfactory arrangements.
It took the worst financial crisis in 70 years to alter that dynamic, along with a bout of mass delusion among moderate Democrats, who somehow convinced themselves that voting to pass Obamacare wouldn’t end their political careers. Whatever else those legislators gave us, good or ill, they also gave us a more “normal” health care politics, in which both the electorate and the elected spend immense amounts of time quibbling over health care policy, even to the exclusion of other things they’d really like to get done.
If Graham-Cassidy passes, it will return us to something more like the health care politics of yore, because the federal government will be (mostly) out of the health care-program business (with the huge and growing exception of Medicare). Feds will provide much of the funding. But the states will be the ones in charge of deciding what the system in their state will look like.
Of course, Democrats can one day undo what Republicans are doing, just as Republicans are planning to undo the work of the Democrats. The left can pass another Obamacare, or some different, more expansive plan. But to do so, they will have to go through the whole painful process of passing Obamacare all over again: soothe or pay off all the anxious interest groups; find the extra tax dollars to fund it; reassure voters who have good insurance that they will not lose by the new plan.
This task will be immensely harder in Round 2 than it was in 2010. By the time they get around to it (in 2020, soonest), Democrats will be forced to scavenge for new sources of funding at the same time as every predator on K Street is scouring the landscape to feed our existing defense commitments and rapidly growing entitlement burden.