Wednesday, May 17, 2017

Also undead: Cassidy-Collins

Rising out of the grave with the monstrous AHCA, or at least wriggling its toes a little, is the more moderate Cassidy-Collins ACA remake bill, dubbed the Patient Freedom Act. That bill, introduced in January, preserves the ACA's funding base and allows states to maintain the Medicaid expansion and, if they wish, their ACA marketplaces in their current form.  

Back in March, in the New York Times online, I urged Senate Democrats to engage on the Cassidy-Collins, if only to shore up Republican Senate moderates in their efforts to stave off roughly matching trillion-dollar cuts to benefits and revenue. I submitted the piece on March 13, and it appeared on March 24, hours before House Republicans pulled the AHCA without a vote. When Paul Ryan declared that "Obamacare will be with us for the foreseeable future," the op-ed seemed insta-obsolete. No more.

On Monday night, as The Hill's Peter Sullivan reports, "A bipartisan group of senators met in the Capitol on Monday night to discuss whether there is a bipartisan way forward on healthcare reform." Politico reports that Democratic senators "Manchin [WV] and Democratic Sens. Heidi Heitkamp of North Dakota and Joe Donnelly of Indiana were spotted in the meeting"; that Claire McCaskill has also talked to Cassidy and Collins; and that Tom Carper (D-Del.) and Angus King (I-Maine) also say they are interested in a bipartisan approach.  Dem Senate leaders Schumer and Durbin have blessed the talks, Durbin on grounds that Cassidy-Collins is not a repeal bill.

This sideshow opens as a much more conservative group of 13 senators appointed by leadership work to create an AHCA-lite, which I suspect will include something like the Medicaid "compromise" floated by four Republican governors positioned as "defenders" of the ACA Medicaid expansion. That proposal offers states a Sophie's Choice: submit to per-capita caps or block grants on Medicaid, or forego enhanced federal funding for the Medicaid expansion population.

The governors who crafted this proposal (Kasich of Ohio, Snyder of Michigan, Sandoval of Nevada, Hutchinson of Arkansas) are among the strongest Republican defenders of the Medicaid expansion. It's hard to imagine that the Republican senators who have "defended" the expansion would not go along. In fact, as I've noted, those who voiced qualms about the AHCA repeal of the expansion called for slowing it down, not scrapping it.

Therefore I think that engagement with the Cassidy-Collins crew is the Democrats' best hope for avoiding Draconian cuts to revenue and benefits and increases in the uninsured population.  Cassidy and Collins have stressed that they are not seeking to pass their bill per se. As I argued in the Times piece, the ghost in Cassidy & Collins' Rube Goldberg machine is a superwaiver solution, in which states have more freedom to take ACA-level funding and devise their own coverage schemes if they so desire.

I think that every argument I made in March remains relevant, and in fact more compelling now than then.  The ACA marketplaces are currently being destroyed by uncertainty and semi-sabotage. Republican moderates have been marginalized in the mainstream bill-writing process.  Price's HHS, meanwhile, has taken us halfway to "superwaiver," encouraging states to submit ACA innovation waiver proposals (which is actually a good thing). Oklahoma is deliberating on an outline waiver proposal that looks very like the alternative to the ACA marketplace established by Cassidy-Collins, in which federal dollars that would have funded ACA premium subsidies instead fund Health Savings Accounts linked to high deductible health plans, and which the OK proposal also would use to serve the potential Medicaid expansion population.

Yesterday, David Anderson (f.k.a. "Richard Mayhew) cast engagement on Cassidy-Collins as low-hanging fruit on Democrats' decision tree:
Not engaging is an all or nothing bet that values politics of playing for a massive wave in 2018 and a trifecta in 2020 to correct the policy damage. If a bill that can get 50 Republican Senators and the Vice President to vote for it gets out of the Senate, it will get out of the House. It will be less bad than the AHCA but it will be very bad from a Democratic policy perspective.

Engagement either leads to burning Senate time if there is no productive grounds for a deal which is a good in and of itself in a normal legislative environment and extremely valuable in today’s climate or a deal that cements the federal role in healthcare where the argument is over which dial to turn and how far to turn it. That returns healthcare to normal politics and cements a massive ideological victory for liberalism bought at the cost of a tactical policy retreat and giving up the ability for Democrats to use healthcare as a board with a nail on it to beat up on Republicans in the 2018 midterms.
I concur. At bottom, this fight is about funding. Any avenue that may stop repeal of ACA taxes and the ACA Medicaid expansion is worth pursuing.

Delay, as Anderson suggests, is a good in and of itself.  The longer the legislative process grinds on, the more likely it is that Republican efforts will be engulfed by Trump scandals, and ultimately by loss of one house of Congress.  In spite of everything, though, I still believe that a more thoroughgoing healthcare truce is ultimately possible, because necessary. To return to the op-ed:
Ultimately, both sides need a deal. The A.C.A. has endured relentless Republican defamation and outright sabotage — most notably defunding of a crucial risk-adjustment program. No benefit program can withstand perpetual assault from one of our two major parties. On the other hand, no party in its right mind takes steps to uninsure tens of millions of constituents.

If the Ryan plan founders, the individual insurance market may very well collapse in the uncertainty. The Trump administration has already taken several measures certain to depress enrollment. While a nuclear blame war will inevitably ensue, the administration and Congress will be forced to take steps to shore up the market.

At that point, perhaps both sides will stagger toward a health care truce — driven in part by the president’s craving to validate his core brand as a deal maker. And there will be Cassidy-Collins, pointing the way toward a superwaiver solution: federal funding for states to take and try to make health insurance affordable for all their residents, by what means they will.

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