The worst thing about the Cassidy-Graham amendment, Republicans’ 11th-hour attempt to repeal Obamacare, is that many millions of Americans would lose their coverage and see their premiums shoot up if they get sick. But only slightly less horrible is the incomparably dishonest way Senators Bill Cassidy and Lindsey Graham have been selling the proposal, which conflicts with a fundamental conservative tenet: that egalitarian policies “punish success.”
This is what you always hear from the right whenever anyone suggests taxing the wealthy even a little bit more. They respond that all Americans have the same opportunities to obtain wealth (they don’t) and we shouldn’t punish those who managed to thrive. It’s simply un-American to penalize those who put in hard work and play by the rules.
But the down-home pitch from Cassidy and Graham breaks with this entirely. They claim their plan instead strikes a blow for equality. “These funds are quite unequally distributed,” Cassidy told health-care reporters, referring to federal health-care spending issued to the states under the Affordable Care Act. “Where you live should not determine how healthy you are.” And here’s Graham on the Senate floor: “I like Massachusetts, Maryland, New York, and California, but I don’t like them that much to give them the money that the rest of us should get!”
Behind this touching concern for American welfare is a simple red-state-vs.-blue-state divide, perfectly timed for an age of polarization. Those Yankees are taking all our money, and we have to get it back. To get to this point, you have to ignore the fact that red states receive a disproportionate share of federal aid overall, and rank higher in terms of how much federal aid they take out relative to federal taxes they pay in.
But dig a hair deeper and you discover a simple fact: The states listed above obtained a disproportionate share of federal health-care dollars because they tried. Operating under the same terms available to every other state, they expanded the Medicaid program and did their best to sign up the uninsured for both Medicaid and the Obamacare exchanges. Instead of denying the poor coverage, they took the bargain offered under the ACA to cover all the costs of Medicaid expansion initially and around 90 percent over time. Instead of making it more difficult to navigate the individual market, or consign people to the federal exchange, these states built their own websites and worked to promote and assist with getting covered.
This was difficult work, finding the uninsured and encouraging them to sign up, spending on outreach in multiple languages, getting people covered. None of it was unavailable to Texas or Alabama or South Dakota. To the extent there are inequities, it’s the fault of those states that chose not to expand Medicaid or put in the time to cover the uninsured. Yet, instead of leveling up every state to bring them to the same level, Cassidy and Graham whine about fairness to level down. And when called on this, Cassidy told reporters that some states don’t want to pony up 10 percent of the cost of making sure poor people have a health-insurance option beyond “rub some dirt on it,” so every state has to suffer.
In other words, the problem with New York and Maryland and California and Massachusetts is that their public officials are too good at covering the uninsured.
Cassidy and Graham have tried to elide the red state/blue state nature of their proposal by pointing to Democratic senators in Florida, Missouri, and Virginia, whose states would “do better” under their plan. But none of those states expanded Medicaid; they’d “do better” with Cassidy-Graham because they did worse by their people previously.
This is all, of course, just a rhetorical framework for Cassidy-Graham’s actual goal of ratcheting down federal support for health care, not just transferring wealth to non–Medicaid expansion states. The plan turns both Medicaid expansion and ACA subsidies in the individual market into a block grant for the states, reduces the block grant gradually over a decade, and then eliminates the funding entirely in 2027, the equivalent of repeal without replace. Cassidy and Graham claim that it could be renewed in 2027, but it would have to be an affirmative appropriation, offset in the budget, with no guarantee of success. In addition, the Medicaid program, separate from expansion, would have a “per capita cap,” which would set an upper bound on per-patient Medicaid funding.
According to the Center on Budget and Policy Priorities, every state loses from this scheme: There are no winners. Federal health-care spending would drop by $120 billion by 2026, with only eight states seeing any increase, and 20 states facing declines of between 35 and 60 percent. In 2027, when the bottom drops out on the block grant, all states would be in the red.
Cassidy and Graham’s numbers, which they like to read from to tell fellow senators how much each state will be getting, are as dishonest as their pitch. CBPP points out, that under current law, the government would spend $241 billion on ACA subsidies and Medicaid expansion in 2026; under Cassidy-Graham it would be $200 billion. That’s the meaningful change, not Cassidy and Graham’s tout that spending would rise over time, as it does ordinarily because of inflation. The incorrect comparison minimizes the true damage and inflates the gains.
But it’s this appeal to equality that really gets me. Conservatives have spent decades proclaiming loudly that we shouldn’t equalize outcomes, only the opportunity to achieve. Now, in one bill rearranging one-sixth of the economy, they claim they’re doing it in the name of equalizing outcomes. It’s so profoundly cynical that I’m almost certain Cassidy and Graham don’t believe it themselves. They stand in the Senate well like country lawyers preaching about fairness in the most transparently insincere way possible. There was nothing unfair about California’s or New York’s taking what was offered in the ACA. Cassidy and Graham want simply to punish success, to take out their partisan anger on vulnerable people whose elected representatives happened to do their job of providing for the general welfare.