E.J. Dionne Jr.: The priority is still to save Obamacare
Before supporters of universal health coverage get all wrapped up debating a single-payer system, they need to focus on a dire threat to the Affordable Care Act likely to come up for a vote in the Senate before the end of the month.
The latest repeal bill is an offering from Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., that would tear apart the existing system and replace it with a block grant to the states. Block grants — flows of money for broad purposes with few strings attached — are a patented way to evade hard policy choices. All the tough decisions are kicked down to state capitals, usually with too little money to achieve the ends the block grant is supposed to realize.
Because Graham and Cassidy are civil interlocutors and have sounded more reasonable than many of their Republican colleagues in talking about health care, there is an unexamined assumption that their proposal must be more sensible than other approaches to repeal.
But's it's not. In fact, it would be disastrous. In certain respects, it's even worse than the earlier repeal measures, which at least kept some of the structure of Obamacare's subsidies in place. This bill would simply blow them up.
It would also shift money around in ways that would, on the whole, hurt states that have been trying to get health coverage to their less affluent residents. A report on the bill by the Center on Budget and Policy Priorities (CBPP), a think tank devoted to the interests of less-advantaged Americans, concluded:
"In general, over time, the plan would punish states that have adopted the Medicaid expansion or been more successful at enrolling low- and moderate-income people in marketplace coverage under the ACA [Affordable Care Act]. It would impose less damaging cuts, or even raise funding initially, for states that have rejected the Medicaid expansion or enrolled few low-income residents in marketplace coverage."
This should make the bill impossible for two brave Republicans, Sens. Susan Collins of Maine and Lisa Murkowski of Alaska, who stood up against July's repeal effort. Both have said they would not be complicit in undermining health care coverage in their states. The CBPP report showed that Graham-Cassidy would reduce federal funding for health coverage in both Maine and Alaska and cut Medicaid overall.
Oh, yes, and the report also noted, with italicized emphasis, that as currently written, the block grant "would disappear altogether after 2026." What happens then? The bottom line, said Jacob Leibenluft, a senior adviser at the center, is that Graham-Cassidy "punts all the problems to governors while giving them insufficient tools and resources to address them."
This is a matter of urgency because the authority the Senate has to pass Obamacare repeal with just 51 votes expires on Sept. 30. So if the bill comes up, it would likely hit the floor in the last week of this month. All who care about the expansion of health care coverage need to focus their energies on defeating this latest attack on Obamacare. However we eventually arrive at universal coverage, which we must, it will be far easier to get there by building on the ACA.
And assuming the latest repeal effort fails, last week's push for a single-payer system could come to be seen as a useful initiative provided that "Medicare for All," as its supporters like to call it, is treated as a goal, not a litmus test. Defining the left pole of the health care debate is helpful, in part because it shows how fundamentally moderate Obamacare is. It is not, as many conservatives have claimed, anything close to a socialist scheme.
And for those whose objective is single-payer, there are many options available that could gradually open the way for it. As Medicare for All's leading advocate, Sen. Bernie Sanders, I-Vt., noted in an underappreciated tweet in July: "In the short-term, to improve the Affordable Care Act, we should have a public option in 50 states and lower the Medicare age to 55." Many progressives and moderates who favor universal coverage but are not yet sold on single-payer would embrace options of this sort. Such measures would help a lot of people immediately and make any move to single-payer less disruptive.
What the country cannot afford is to go backward, which is where Sens. Graham and Cassidy would move us. Politics is about priorities, and the priority now must be to stop Congress from ripping health coverage away from millions of our fellow citizens.
— E.J. Dionne's email address is firstname.lastname@example.org. Twitter: @EJDionne.