The Graham-Cassidy bill is the Republicans’ latest effort to “repeal” Obamacare. Named for its two Republican Senate sponsors, the bill doesn’t just end the exchanges, subsidies and mandate that make the ACA work. It bundles all federal expenditures for both Obamacare and Medicaid into block grants, and disburses that money to state governments to use basically as they see fit. It will let states waive the ACA provision that prohibits insurers from gouging people with preexisting conditions, or selling junk plans that don’t cover basic and essential services.
As it currently exists, Medicaid is administered through state governments. But it relies on guaranteed federal funding, which adjusts as need levels rise and fall in individual states. Block grants would instead disburse federal Medicaid funding according to a preset allotment formula. That formula purposely underfunds Medicaid so that it does not keep pace with inflation over time. Eventually, the entire program will collapse.
And that’s the point. Put aside all of the insultingly disingenuous rhetoric from Republicans about states being in a better position to administer healthcare for their citizens. They want to murder Obamacare and Medicaid. They always have. Block grants are just the means by which they intend to do it.
But in the near term, the Graham-Cassidy bill—if it passes—will send a large chunk of grant money to the states. Beginning in 2021, much of it will be redistributed to states that refused to accept additional federal funding to expand Medicaid for their citizens in 2015. One of the biggest beneficiaries of this redistribution will be Texas, whose governor made much fanfare of his decision to reject expanded Medicaid funding for low-income Texans two years ago.
There are a lot of great pieces explaining why Graham-Cassidy is such a terrible policy proposal on the merits. Senate Republicans themselves can’t articulate a single compelling reason to pass it, aside from the fact that it gets rid of Obamacare and placates their donors. They know that their bill will kill people if it becomes law, and they’re probably aware that it makes universal health care more likely in the long term. But abstractions like "other people" and "the future" have never given these folks much pause.
Hopefully, this bill will go the way of previous repeal attempts. But let’s just imagine for a moment what the next five years will look like if Graham-Cassidy actually passes. Specifically, let’s imagine what it will look like in Texas, where I happen to live. If Graham-Cassidy passes, my state will receive a significant (if temporary) windfall with almost no strings attached.
Texas, whose legislature only meets every other year, and routinely fudges numbers with reckless abandon in order to pass its budgets. Texas, whose Senate passes the most transcendently reactionary bills in the country, and whose House membership includes this jackass. A state run by people so hostile to the very idea of public health assistance that they’ve already turned down billions of free federal dollars for exactly that purpose.
If Graham-Cassidy passes, these are the people who will decide what happens to Medicaid in Texas. These are the people who will control the money that currently sustains Texas’ dwindling number of rural hospitals, and provides health coverage to hundreds of thousands of poor children, parents, pregnant women, seniors, and people with disabilities. These are the people who are supposed to craft health care solutions that keep people insured, and prevent insurers and hospitals from ripping people off. They are the people whom Graham-Cassidy entrusts with keeping vulnerable Texans from dying for no good reason.
The best way to predict how that would turn out is to look at how Texas has (mis)used block grants in the past. The Temporary Assistance for Needy Families (TANF) block grant program replaced the Aid to Families with Dependent Children (AFDC) program as part of a major welfare reform effort in 1996. (Seriously, thanks again, Bill.) TANF block grants were supposed to be used by individual states to support poor families with children as parents looked for work.
But that’s not what Texas used its TANF money for. In fact, Texas ranks dead last among states for the share of TANF funds it spends on “core” program activities. According to the Center on Budget and Policy Priorities:
In 2015, for every 100 poor families with children in Texas, only 5 received TANF cash assistance, down from 24 in 2001. During that time, Texas slashed its spending on basic assistance and eliminated spending on child care, even as the number of families with children below 50 percent of the poverty line increased.
What did Texas do with the TANF block grants instead? It plugged budget holes, and redirected TANF money to unrelated state programs, such as its failing child protective services. In other words, Texas used its TANF grant money as a slush fund. As a result, the number of families with poor children in Texas has risen substantially over the past ten years, while the cash assistance caseload has dropped by almost half.
Past is prologue, and anyone who thinks that the Texas state government will do even an adequate job of administering federal Medicaid dollars is crazy or lying. My state’s example gives the lie to the Republican canard that state governments are better positioned to “provide solutions” when it comes to healthcare. The fact that Texas will get more money out of Graham-Cassidy than any other state just adds bitter insult to terrible injury.