During the House of Representatives’ recent appalling debate over health-care reform, pundits liked to point out that the Senate is the more deliberative, serious body. The upper chamber, with its powerful moderate Republicans, would of course craft something more reasonable than the House bill. Instead, the Senate made the lower chamber look like a bastion of civil democracy. Thirteen far-right white men went off in a corner and set the terms for the bill that would eventually emerge—one that the Congressional Budget Office estimates will cost 22 million people their health insurance by 2026, primarily by ending America’s decades-old commitment to giving the country’s poorest residents access to health care.
Institutions are important. Our government is built on a system of institutional checks and balances that are meant, in part, to rein in extremism. One reading of the first six months of the Trump era is that those institutions work: The lower courts, at least, blocked the travel ban, Congress is conducting investigations, and journalism is rising to the challenge of an administration hostile to the First Amendment. But institutions are only as strong as the principles of the people in them. And an alternative reading of the Trump era thus far is that the people who pride themselves on being the serious, principled keepers of our institutions are missing in action.
That’s certainly the story of the Senate’s health-care bill. It’s not yet clear, as this column goes to press, how the chamber will vote. But it is already clear that there will be nothing like a meaningful discussion of health-care policy under the current Senate leadership. There are certainly important questions to be asked about insurance markets under the Affordable Care Act, and about how to manage Medicaid’s share of both state and federal budgets. But if we were really debating those things, the Senate’s bill would be a nonstarter for several people in the Republican caucus.
Consider two senators, Rob Portman of Ohio and Shelley Moore Capito of West Virginia. They represent two of the states that would be most devastated by either the House or Senate bill, and both have reputations as moderate, serious Republicans who can be counted on to hold the reasonable center against the extremes of American politics. How did they react when Senate majority leader Mitch McConnell finally allowed us all to see the bill that he and his white male colleagues had crafted? Both senators quietly wrung their hands over its vision for Medicaid—while any honest reading of the bill should have sent them screaming to the ramparts of the resistance.
The largest, most consequential proposal in the Senate bill is the same as in the House version: ending Medicaid as we know it. It’s not just a repeal of the Affordable Care Act’s Medicaid expansion; both bills would cripple the federal government’s partnership with states on health insurance for the poor and disabled. Rather than paying a fixed share of all costs, the federal contribution would be capped and dispersed in a block grant to each state. Which is to say, states would be left holding the fiscal bag on a program that is second only to K–12 education in most state budgets.