This progression has unfolded at warp speed, by Washington standards. After Graham-Cassidy started gaining minimal traction a few weeks ago, very few people seemed to pay it much heed -- but as more conservative voters began to recognize that Republican Senators had another realistic shot at replacing Obamacare before the (potentially flexible) September 30 reconciliation deadline, pressure started to mount. We asked whether GOP leadership would guarantee a floor vote on the measure, having farmed out the task of whipping colleagues to the bill's sponsors. Then the White House started to wade into the situation, tentatively at first, then emphatically. And now Mitch McConnell appears to be gearing up to call a vote on the proposal next week:
NEWS: McConnell Intends to Take Up Graham-Cassidy Bill Next Week— Erik Wasson (@elwasson) September 20, 2017
"Intends" stands out as a wiggle word. My guess is that McConnell isn't sure whether they'll get to 50, and likely knows he has zero margin for error. If Rand Paul and Susan Collins are in Schumer's column, Republicans cannot lose a single additional vote, with members like John McCain and Lisa Murkowski (whose governor is opposed to the bill) still sitting on the fence. Having gotten burned by renegade members of his own caucus in a dramatic showdown over the summer, I can't imagine a cautious leader like McConnell presiding over another high-stakes vote on which the outcome is uncertain. So today's announcement smells like a pressure play to me. Fox News' senior Capitol Hill producer Chad Pergram agrees:
McConnell office saying they intend to vote on health care vote is way to to amp up the pressure on the undecideds over the weekend.— Chad Pergram (@ChadPergram) September 20, 2017
Might it be possible to pull Paul back into the fold? Or is he really on a mission to potentially single-handledly save Obamacare by torpedoing "Obamacare Lite"? It's looking like the latter:
#GrahamCassidy is amnesty for Obamacare. It keeps it, it does not repeal it. I will keep working with the President for real repeal.— Senator Rand Paul (@RandPaul) September 20, 2017
National Review's editors are urging Kentucky's junior senator to reconsider his position, seriously questioning his strange and shifting justifications:
Rand Paul, the Kentucky Republican, has one thing right: The latest Republican bill on health care is not a repeal and replacement of Obamacare. Under it, the Affordable Care Act’s taxes, spending, and regulation would mostly remain in place. Of course, previous Republican bills left a lot of Obamacare in place, too. For many months it has been clear that Republicans do not have the votes for a true replacement. Where Paul is wrong is in opposing the Graham-Cassidy bill on that basis. A true replacement of Obamacare would be better than Graham-Cassidy, but Graham-Cassidy is still much better than Obamacare. It abolishes the individual and employer mandates, caps per capita spending on Medicaid, blocks federal funds from going to insurance plans that cover abortion, and lets interested states attain freedom from some of Obamacare’s regulations...The bill goes farther in the right direction than the “skinny repeal” bill for which Paul voted earlier this summer. That bill abolished only the individual and employer mandates...There has been widespread speculation that Paul is playing a game on Obamacare: that he does not really wish to see major changes to it and will find libertarian-sounding objections to any Republican bill that has a chance of passage. This speculation may be unfair. But Paul’s arguments for a no vote make so little sense, and are so hard to square with his previous votes, that it is getting harder to dismiss.
President Trump, who is quite popular in Paul's home state, has joined in on the lobbying efforts via Twitter:
Rand Paul is a friend of mine but he is such a negative force when it comes to fixing healthcare. Graham-Cassidy Bill is GREAT! Ends Ocare!— Donald J. Trump (@realDonaldTrump) September 20, 2017
Question, though: Might at least one of Paul's practical arguments against the bill make some sense? At the Weekly Standard, John McCormack outlines the Senator's critiques of the bill: "it keeps too much of Obamacare's spending, it's funding formula takes from Democratic states and gives to Republican states, and its 2020 implementation date is too soon for states to smoothly transition away from Obamacare." As McCormack and others have noted, Paul voted for a pared-down "skinny" bill that kept virtually all of Obamacare's spending intact, so number one is an unconvincing objection. The second concern is a natural outflow of seeking to equalize federal treatment among states in such a way that no longer tips the scale in favor of rich, benefit-heavy blue states. Mr. Libertarian objects to this...why? His final point strikes me as fair. Senators should consider whether the 2020 time horizon is realistic for all 50 states to re-establish a post-Obamacare patchwork, even as many of the federal law's regulations would remain in place. Similarly, on the back end, is there a creative way to avoid or mitigate the 2026 "cliff" when Graham-Cassidy's funding would expire and need to be renewed by a future Congress? These are reasonable questions that deserve careful attention; unfortunately, due to Republicans' self-inflicted time box, such decisions will necessarily be rushed.
As Graham-Cassidy is debated over the coming days, I'll leave you with a few reminders: (1) Its supposedly draconian cuts are neither draconian (see here) nor genuine cuts (spending levels would still rise year-over-year, but at a less steep rate). (2) Medicaid was badly broken before Obamacare's huge expansion of it, which perversely and disproportionately prioritizes less poor, able-bodied, childless adults over the most vulnerable people in the program. That's grossly unfair. Reforming Medicaid and at least putting both Medicaid populations on equal footing are necessary and fair goals. (3) Block-granting funds to states in order to incentivize efficiencies, fiscal discipline, and pro-patient outcomes isn't just a talking point:
Important WSJ editorial on state-level Medicaid innovations that save billions w/o hurting eligibility or services: https://t.co/meYeo3gVIS— Guy Benson (@guypbenson) July 13, 2017
(4) in the mid-1990's President Clinton proposed a Medicaid reform that would impose a per capita cap structure. At the time, all 46 Senate Democrats endorsed the idea, our entitlement-fueled debt crisis has deepened significantly since then. A cynic might be forgiven for concluding that today's outraged opposition to the concept is about anti-math, reckless, petty politics, instead of "helping" people.