As Congress factors in Sen. John McCain’s refusal to back, for now, the latest scrupulously unvetted legislation to scramble the American health care system, the gamey smell of states’ rights still lingers in the air.
“Instead of a Washington-knows-best approach like Obamacare, our legislation empowers those closest to the health care needs of their communities to provide solutions,” said Republican Senator Lindsey Graham, co-sponsor of the latest scratch at the Republican itch to destroy Obamacare anyway, anyhow. “Our bill takes money and power out of Washington and gives it back to patients and states.”
For advocates of quality health care, broadly delivered, Graham’s paean to the county courthouse smells as healthful as a gust of napalm in the morning.
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Even if the Graham-Cassidy bill doesn’t survive the rush to pass it before the fiscal year ends at the end of September, the legislation can resurface in the next fiscal year. Its chief selling point never grows stale in Republican circles. It promises to unleash the innovative powers of the states by reducing the amount of money Americans have to afford health insurance. Unlike previous GOP proposals, which merely sought to deform Obamacare beyond recognition, this legislation would indeed destroy it.
It would repeal the Affordable Care Act’s coverage ownership and offer mandates, and replace its premium and cost-sharing subsidies and Medicaid expansion with block grants to states. It would abandon commitments to essential benefits in policies and to regulations preventing discrimination on the basis of pre-existing conditions.
Much attention has been focused, rightly, on the massive transfer of federal resources the bill envisions from blue states to red states. The Kaiser Family Foundation estimates that from 2020 to 2026, block grants would boost federal health spending in Mississippi by 148%. New York, meanwhile, with more than six times the population of Mississippi, would see its funding cut by 35%.
The point, Republicans say, is to rectify Obamacare’s unfairness to states. “Those funds are quite unequally distributed,” said Sen. Bill Cassidy of Louisiana, explaining why the most Democratic states would lose under his legislation and the most Republican states would gain. “Where you live should not determine how healthy you are.”
Of course, geography has nothing to do with access to federal subsidies for health insurance, except to the extent that Southern politics is a state of mind. States controlled by conservatives, such as Mississippi, have opted out of Obamacare’s Medicaid expansion, adamantly refusing federal aid to their own poor and working-class citizens. The money is available. Conservative politicians just refuse to take it.
Yet these same hidebound state capitals, many operating under the same ideological, class and racial prerogatives that have dominated them, and restricted opportunity in them, seemingly forever, are now destined to become laboratories of beneficent social innovation under Republican block grants.
There are 19 states that refused to extend health insurance to their poor and near-poor citizens when the federal government was willing to pay 100% of the initial Medicaid cost and 90% over time. Those states will not suddenly become hotbeds of innovative health care delivery when the federal money is reduced, and transformed, into a block grant.