Opinion: If Congress can’t do it, let the states fix Obamacare

U.S. Sen. Lindsey Graham (R-S.C.) speaks as Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), Sen. Ron Johnson (R-Wis.) and former Sen. Rick Santorum (R-Pa.) listen during a news conference on health care, Sept. 13 in Washington (Olivier Douliery/Abaca Press/TNS)

The latest iteration of a Republican anti-Obamacare bill is being bandied about the Senate GOP caucus. The dirty not-so-secret is that, in significant ways, it isn’t Obamacare repeal so much as Obamacare reform. But in other significant ways, it could be better than the previous repeal efforts Congress has tried this year.

The bill, known as Graham-Cassidy and sponsored by Sen. Lindsey Graham of South Carolina, Bill Cassidy of Louisiana, Dean Heller of Nevada and Ron Johnson of Wisconsin, repeals certain aspects of Obamacare but leaves others in place. Gone: the individual and employer mandates, as well as some of the taxes (including those on medical devices, health savings accounts and Medicaid providers). The Medicaid expansion would effectively end in 2020, although the amount of federal funding devoted to the program would continue to grow between now and then, and afterward as well — on both aggregate and per capita bases.

Remaining in place, aside from most of the spending, are most of the taxes and many of the regulations (at least until HHS Secretary Tom Price can change those regs through the normal process). If you want the federal government out of health care, or even back to the level of intervention that existed before Obamacare, you are going to be sorely disappointed.

One unfortunate truth revealed during the current debate, however, is that there is not much political will for returning to that status quo ante. The scare-mongering about projected coverage losses, exaggerated though they were, worked. (You’ll no doubt hear more scare-mongering about coverage losses from this bill, as you would about any GOP health bill — even though we know the earlier estimates were fatally flawed, even though the Congressional Budget Office hasn’t scored this bill yet, and even though scoring a bill that shifts much decision-making authority to the states would be virtually impossible given the many different and unpredictable ways they would implement it.) And as we discussed yesterday, most Americans are content to let Uncle Sam continue to pile up the debt. The fact that the GOP is reduced to considering a bill like Graham-Cassidy reflects these realities.

That said, all is not lost. The bill would enhance HSAs, allowing Americans to put more money into them and use them to pay insurance premiums or direct primary care. That’s a big win for those who want to see us move away over time from so much reliance on third-party payers. The bill also includes the so-called Cruz amendment, which would allow insurers to offer catastrophic-only plans that cover less but at a lower cost, if they offer other plans compliant with all of Obamacare’s coverage mandates. That should help put downward pressure on premiums, although it’ll be less effective without substantial changes to high-risk pools. If we are going to subsidize patients with expensive health conditions, we need to do it in a way that doesn’t drive up premiums for others and lead to the kind of death spiral Obamacare is beginning to experience in the individual market.

The biggest plus here, though, is the way it shifts most of the decision-making for health care down to the states.

This is good from a philosophical standpoint — in general, we get better decisions when they’re made closer to those they affect. But the entire Obamacare and now Obamacare-repeal debates have illustrated why it’s good from a practical standpoint.

In short, a nation of more than 320 million people (and growing) is unlikely, and increasingly less likely, to agree on broad policies for such an important issue as health care. There is never going to be an approach to something as complex and personal as health care that is welcomed equally in New York as it is in Texas, in Georgia as it is in California. Our size and societal diversity are oft-neglected reasons we don’t have the same, universal approach to health care seen in smaller industrialized countries, such as those in Europe. We don’t have the same kind of social consensus that exists in those countries — and certainly not the kind of consensus that existed when most of those systems were created, in the mid-20th century. Heck, we don’t even have the same kind of social consensus many Americans knew earlier in their lives. Trying to force a policy solution on this entire country, in the glaring absence of that kind of consensus, simply isn’t going to work, whether it’s the kind Ted Cruz would favor or the kind Bernie Sanders would cook up. We will end up fighting this fight forever.

So stop trying to do it. Let California proceed as it wishes, and give the same latitude to Texas. But if they run up the red ink, or if their people suffer, don’t bail them out. Let their voters choose leaders who will fix whatever problems they create.

In doing that, the federal government ought not to favor one approach over another from a fiscal standpoint. Yet that’s exactly what we have had in past decades through Medicaid. A spreadsheet by the authors of Graham-Cassidy shows that, while Medicaid’s average spending per beneficiary was $2,684 in 2016, it ranged from $373 in Mississippi to $10,242 in Massachusetts (Georgia’s was $823). Some of this reflects the higher match rate for those included in Obamacare’s Medicaid expansion, but it also owes to the way high-spending states have milked Medicaid for money on non-expansion enrollees.

Graham-Cassidy would level the playing field, increasing spending per beneficiary to $4,419 by 2026 but narrowing the range: from $4,372 in Wyoming to $4,418 in California (Georgia’s would be $4,417; there’s also a uniquely large jump to $6,495 in Alaska, for reasons I don’t understand unless it’s just a blatant attempt to get Sen. Lisa Murkowski to vote for it).

What’s not clear to me is how much freedom states would have to adjust the number of people they cover with that money. Done right, the result ought to be more motivation for higher-spending states to seek efficiencies, while lower-spending states cover more people.

And that’s where the onus ought to be. States should have the flexibility to cover their populations in the ways that make sense for them, while facing the pressure to lower health costs per person.

If that works, other reforms might be possible in the future. Congress has to re-learn the art of taking what it can get today, and then try for more tomorrow. As things stand, this looks like the best chance for now to begin cleaning up the mess Obamacare has made.

Reader Comments 0

102 comments
peyaxeb
peyaxeb

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mbrown99
mbrown99

If this Congress can't fix healthcare, elect another one.

FIGMO2
FIGMO2

Let the states fix Obamacare?

Aaahhhh, the laboratories of democracy. Truth is...Obamacare was built on progressive federalism. It's why I viewed Mitt Romney as a questionable GOP nominee.

Anyhoo...the march is on for single-payer in Massachusetts. 

If single-payer is meeting resistance in California, chances are, it'll face resistance in Massachusetts too.

Perhaps the cost of living in both states is too damn high? So high that folks have moved to states where the cost of living is within reason? Blue states have succeeded in pricing their residents right out of the market but want the federal government to pay for their mistakes

States have allowed themselves to become way too dependent on the federal government. 

CSR (Cost Sharing Reductions) 'cause sharing is caring, amirite? 

schnirt


LogicalDude
LogicalDude

@FIGMO2 "Obamacare was built on progressive federalism"


Can you tell me what that even means? 


Is Social Security "progressive federalism"? Medicare? Medicaid?  Because people really seem to think those are good ideas, and "not a bad thing" like you are trying to make it sound. 

DawgDadII
DawgDadII

These programs target groups where there is social risk they cannot support themslves and become a burden to or moral and ethical dilemma for others. Obamacare has similar intentions but in its form it is over restricting and burdensome on thee mainstream of society it should be leaving alone.

Social Security is a multi-faceted insurance, annuity, and welfare program. Once a person has funded it the government has a moral and ethical responsibility to live up to its obligations. But it leaves one seriously wondering "what if" I had paid a welfare tax all the years and had the rest of the money invested in private insurance and retirement plans.

FIGMO2
FIGMO2

@LogicalDude @FIGMO2

Actually, Medicare and Medicaid are progressive federalism.

Sad to say, Medicaid is the new Medicare just longer term.

Old age is inevitable and can be crippling. 

All too often, it's Medicaid that cripples.


# FU 417
# FU 417

What a freaking dumb idea!!  The states will only screw minorities and this dirty low down state refuse to accept Subsidies from the gov't to insitute Affordable care. Republicans only have ignorant, stupid and racist ideas

McGarnagle
McGarnagle

@# FU 417


Well we know rural GA is getting hammered and in need of help. Will these block grants help?

DawgDadII
DawgDadII

Much more responsible to let status quo stand? At this point that is the only alternative.

The illogic of your statement is astounding. If government closer to the people and their control will only screw them, what logically does that tell you the effect on them of the Federal government would be? Or is?

FIGMO2
FIGMO2

@# FU 417

States where those screwed minorities can move to:

Hawaii, D.C., New York, California, Massachusetts, Connecticut, Maryland, Vermont.

The cost of living will kill 'em but they're blue states, sooooo....liberal policies and programs will prevail.

schnirt

TheRealJDW
TheRealJDW

"In short, a nation of more than 320 million people (and growing) is unlikely, and increasingly less likely, to agree on broad policies for such an important issue as health care. There is never going to be an approach to something as complex and personal as health care that is welcomed equally in New York as it is in Texas, in Georgia as it is in California"


Sounds like an argument for the "American Union" Guess splitting off defense is next.  After all how can you expect a state to manage spending without giving them access to the parts.  Be really interesting to watch how the population shifts.

Visual_Cortex
Visual_Cortex

Don't know if Kyle's still around, but if he or any other policy-wonks see this, I'm genuinely interested in an answer.

This seems almost too bizarre to be correct, but I've heard it in a couple of places now.

Really, less than two minutes of debate time left for the Graham-Cassidy bill?

http://americablog.com/2017/09/graham-cassidy-obamacare-repeal-get-2-minutes-debate.html

Even I have a hard time believing the GOP Senators would be quite that irresponsible, but...

Is this really true? Once the bill's introduced they can literally debate it for only two minutes? That they'd used up all the 20 hours on the last "skinny repeal" bill?

McGarnagle
McGarnagle

@Visual_Cortex


This is to my point earlier. This bill feels rushed. But I think Repubs are at a point where they don't care anymore. They have the mindset of Lets just pass something. anything.

LogicalDude
LogicalDude

@McGarnagle @Visual_Cortex " They have the mindset of Lets just pass something. anything."


And not actually allowing actual debate, hearings, testimony and such really damages the credibility of Republicans who actually want to help. I'm sure a bunch of Republicans just want a "win" no matter how damaging it is, but others actually want to improve the system for their constituents.  "Maybe" they think they can "do something" once this travesty is passed. 

Similar to Trump throwing DACA folks under the bus, then saying "congress really should do something about those poor DACA folks." 

Visual_Cortex
Visual_Cortex

@LogicalDude @McGarnagle @Visual_Cortex

If they pass this, I sure hope that sweet, sweet dark money promised from Koch, Mercer, et al, was worth it, because any Democratic challenger worth a damn is going to do everything to nail them to the cross over this vote.

And I'll be there with a hammer and rusty spikes if needed.

Caius
Caius

From the Deaton & Case study as reported in NY Times 11/2/15:"The mortality rate for whites 45 to 54 years old with no more than a high school education increased by 134 deaths per 100,000 people from 1999 to 2014."




McGarnagle
McGarnagle

So whats the likelihood of this passing. Seems 50/50.


Paul said No. The two female republican senators are iffy (Collins and the other one). McCain is iffy.


I'll give the Repubs credit that they presented something that doesn't repeal Obamacare. Probably should have gone with this instead the repeal bills that failed the first few times.

Visual_Cortex
Visual_Cortex

@McGarnagle

It passive-aggressively DOES repeal it, though. By "throwing it back to the states" they're rewarding those who spat at the PPACA by refusing to expand Medicaid and severely weakening those who did.

And the bill essentially wipes out all the "Patient Protections" in the PPACA, telling the states it's a-ok to let insurers charge whatever they like for those people who (say) make the Poor Choice to get a cancer diagnosis.

LogicalDude
LogicalDude

"Our size and societal diversity are oft-neglected reasons we don’t have the same, universal approach to health care seen in smaller industrialized countries


Because people keep getting lied to by saying "it's impossible" or "your money goes to moochers!" when the fact is, the right thing to do is universal healthcare.  If we had some semblence of universal coverage, the discussion wouldn't be "should we have it", it would be "how do we improve it?"  


It's insane to think we do not have universal coverage in the "best country in the world."  We can't even take care of the least of us by having medical coverage?  

Yeah, I'm not blaming those "oft-neglected reasons" of "size and societal diversity." I'm blaming those who keep saying "pay us more money" and buy congressmen who then ignore the suffering Americans. 

LogicalDude
LogicalDude

Amazing quote from VC's link below: "One Texas-based donor warned Republican lawmakers that his “Dallas piggy bank” was now closed, until he saw legislative progress.

Get Obamacare repealed and replaced, get tax reform passed,” said Doug Deason. “Get it done and we’ll open it back up.”"


yeah, do you think those congressmen he is talking to are thinking about the best system for their people or are they thinking about that money coming in from a rich donor? 


Yeah, that's what I thought. 

SGTGrit
SGTGrit

@LogicalDude 

"Suffering Americans" has been a canard generally speaking because those in serious need of healthcare have been able to obtain it if they sought it. This availability of healthcare in America has been around long before Obamacare and the lefts cry for single payer or universal healthcare. Universal healthcare is a political cause that most of the Democrat rank and file don't understand other than it sounds good and their political party favors it for political motives. They don't understand the financial implications nor the functional implications of such an entitlement.

Visual_Cortex
Visual_Cortex

@LogicalDude

Yeah, it's that can't-do spirit of Kyle's as expressed in this piece that I find so dispiriting. He's basically giving up on us being a unified country and wants it Balkanized a bit, in order to get this agenda item cleared.

That's a mindset I'll fight as long as I draw breath.

Visual_Cortex
Visual_Cortex

@SGTGrit @LogicalDude

Universal healthcare is a political cause that most of the Democrat rank and file don't understand other than it sounds good and their political party favors it for political motives. 

It's a pretty dang complex issue, but I think it's ridiculous to imagine that somehow the Republican rank-and-file understand it any better than their political opposites. I feel like I do actually grasp these issues pretty well (having followed the ups and downs of the fight over the past 20+ years, and super-closely since 2009) and I sometimes grimace when I hear what elected officials get on the TV and spew as if it were factual. 

And yes, I've winced hearing both Rs and Ds doing the spewing.

LogicalDude
LogicalDude

@SGTGrit @LogicalDude "This availability of healthcare in America has been around long before Obamacare"


You mean, we have 100% coverage already? WHO KNEW!!!!  


You might want to let all those uncovered folks know they really are covered, and by the way, who is paying for it?  Why can't we just move to a formal "universal healthcare" system if it's already being paid for?  Astounds me that people think it cannot be done. 

Wascatlady
Wascatlady

Yeah, let's let the states also determine requirements for voting!  That worked out well before.


Seriously, we know what Georgia will do.  Everything on the cheap for the "job creators."  For the people?  Meh.

Kathy
Kathy

Congress had seven years to come up with a health care plan. Now they want to kick it to the states to solve it. So, why are we paying Congress to continually do nothing  that might effect their reelection?  Other countries manage to come up with health care plans that protect citizens. Shameful lemmings who always float in the direction of the votes.

Visual_Cortex
Visual_Cortex

 for reasons I don’t understand unless it’s just a blatant attempt to get Sen. Lisa Murkowski to vote for it)

OMFG.

Golly, Kyle, ya think maybe the sk#nks who are trying to push this bloody abortion of a bill through in order to keep that Koch money a-flowin' for the mid-terms* might just make such a move for that reason, rather than noble conservative principles?

Otherwise, golly gosh, I too just don't understand!


--

* see also

https://www.theguardian.com/us-news/2017/jun/26/koch-network-piggy-banks-closed-republicans-healthcare-tax-reform

Visual_Cortex
Visual_Cortex

And for those too timid to get Guardian cooties by clicking the link above:

At a weekend donor retreat attended by at least 18 elected officials, the Koch brothers warned that time is running out to push their agenda, most notably healthcare and tax reform, through Congress.

One Texas-based donor warned Republican lawmakers that his “Dallas piggy bank” was now closed, until he saw legislative progress.

Get Obamacare repealed and replaced, get tax reform passed,” said Doug Deason. “Get it done and we’ll open it back up.”

Nonetheless, Koch officials said that the network’s midterm budget for policy and politics is between $300m and $400m.

Mandingo
Mandingo

After reading this article I fully understand what opinion column means. Not sure why Wingfield would write this dribble. Based on the assumptions in this article we may as well abolish the United States of America. Senators, Congressman and the President serve no useful purpose because of low morals and a misguided value system. The GOP has won  and achieved their goals !!!!!! Every man for himself .

TruthReallyHurts
TruthReallyHurts

Repubs squeal like little girls about "wealth distribution," but this plan is wealth distribution on steroids ... but with millions of lives at stake. Blue states and those states with govs smart enough to expand medicaid, will subsidize healthcare for red states -- who, statistics show, have the most out-of-shape, unhealthy folks, and take more from federal coffers than they contribute.

As I've always said, Repubs/neo-cons are the most hypocritical people on the planet. 

Visual_Cortex
Visual_Cortex

@TruthReallyHurts

Your unhelpful stereotyping aside, this point can't be made clearly enough--yes, it is punishing the states who did the right thing (and they're not all blue states, this is also Republican-run Ohio and Kentucky, among others, who'll get screwed bigly) and rewarding the psychopaths who were fine with people dying (I'm looking at you, Governor Deal), who could've been covered, but we can't do that because Principles and Freedom.

jhgm63
jhgm63

Well, if it passes, I will love hearing how it is "better", especially to those who end up losing their coverage ... 

Starik
Starik

@jhgm63  Better for people with money, influence or both. Certainly in this state and its neighbors. 

TheCentrist
TheCentrist

SOCONS lead by Tom Price spent 8-years and all they can come up with is a pathetic plan that even 70% of their supporters couldn't stomach and now an extremely flawed block-grant scheme?

TheCentrist
TheCentrist

If the "States," especially the SOCON ones have no idea what to do.  Otherwise, the governors would have simply sent their social conservative based comprehensive plan to their congressional representatives.



SGTGrit
SGTGrit

I like the concept of states having control as to how to implement healthcare in their respective states. The federal government still has too much control but that can be tweaked over time. Hopefully, the Republicans will get on board and pass this bill as it may be our last best chance to stave off the Democrats who want a single payer at any cost.

Starik
Starik

@SGTGrit  Even in the Southeast? Where government has always been low tax poor service? 

Here's_to_Blue
Here's_to_Blue

"So, depending on how much flexibility states have to use the new funds, Georgia could potentially cover more people and eliminate uncompensated care."


So . . . Georgia would have the flexibility to cover more people with crappy insurance plans that pay for virtually nothing -- which would be exactly the outcome of this bill.

RoadScholar
RoadScholar

How about preexisting conditions and kids up to 26 years old covered under their parents policies?

Kyle another problem may be , by moving to another state, you have different rules and regs and costs which may attract people, which may place a burden on that state. it's like gay recognition...how can you be recognized and legal in one state and illegal in another? The rules and regs should be universal.

Kyle_Wingfield
Kyle_Wingfield moderator

@RoadScholar Somehow, people manage differences in rules and regs in every single other aspect of their lives when they move from one state to another. And currently, they're almost certainly going to be changing health plans if they move to another state (unless they work for a self-insured company, in which case nothing changes ... which would also be true under this bill).


TheCentrist
TheCentrist

@Kyle_Wingfield @RoadScholar  Very few of those other "rules and regs" are life critical.  Besides, these are not "health plans," but rather plans to pay for healthcare services.

Hedley_Lammar
Hedley_Lammar

 Let California proceed as it wishes, and give the same latitude to Texas. But if they run up the red ink, or if their people suffer, don’t bail them out.


California already gets back only 70 some odd cents on every dollar sent in via taxes. Where does that money wind up ? Poor red states. Southern red states depend heavily on subsidies from richer blue ones. Always have.


Leave each state to its own devices ? That would not end well for poorer red states. 

Kyle_Wingfield
Kyle_Wingfield moderator

@Hedley_Lammar And heeeeere's Hedley with a stat that was handy but irrelevant.

We aren't talking about ending the federal government, we're talking about block grants for certain health-care programs.

Hedley_Lammar
Hedley_Lammar

@Kyle_Wingfield @Hedley_Lammar So just the piece of the pie that works politically ?


No. No half measures. Go all the way.


See how that works out.


The point is a rich state like California could easily afford single payer etc. If not for all the money she spends supporting other states.

Kyle_Wingfield
Kyle_Wingfield moderator

@Starik @Hedley_Lammar Maybe you need to remember which century we're in -- in the 21st century, states have a lot less power than the Framers gave them. In fact, maybe that's the problem.

Kyle_Wingfield
Kyle_Wingfield moderator

@Hedley_Lammar To pre-empt your likely response: The Tax Foundation study that showed 78 cents on the dollar also added extra dollars "paid" to account for the federal deficit. In terms of actual dollars paid/received, it's 99 cents on the dollar. (This is why most states get back more than 100 percent of what they pay in -- we're borrowing most of that money above 100 percent.)

http://www.latimes.com/politics/la-pol-sac-california-federal-government-money-20170205-story.html