Senate Republicans know very little about what their new health-care plan would actually do. This is because the bill’s primary author left the Senate in 2006, and the legislation he wrote has been public for all of eight days. “If there was an oral exam on the contents of the proposal, graded on a generous curve, only two Republicans could pass it,” a senior Republican aide told a reporter this week — before stipulating that the bill’s putative co-author, Lindsey Graham, was not one of them.
But you need not take an anonymous aide’s word on it. On Tuesday, Vox’s Jeff Stein asked nine GOP senators what problems the Graham-Cassidy health-care bill solves, and how it solves them. The lawmakers responded with platitudes about federalism, the phrase “read the bill and you’ll understand,” and a bizarre reference to the final scene of Thelma and Louise.
Still, Republicans know a few things about their latest iteration of Trumpcare. They know that the bill reforms one-sixth of the American economy so radically the Congressional Budget Office will need weeks to generate a detailed analysis of its likely effects; that every major health-care-industry stakeholder — from doctors and patients and hospitals to insurers and medical charities — opposes the legislation; that seven of their own party’s governors also oppose it; that health-care-policy analysts believe the bill would make health insurance unaffordable for many people with preexisting conditions; that it would radically reduce Medicaid and federal subsidies for health insurance; and that some analysts say those cuts would increase the ranks of the uninsured by 32 million over the next decade.
And yet, according to reports, at least 48 Republican senators are ready to vote for the bill next week. Which raises the question: Why is almost every GOP senator ready to vote for widely reviled legislation that they do not understand?
The popular answer is that they feel a political obligation to make good on their promises to the conservative base, regardless of the implications for public policy. Remarkably, several senators have stated, explicitly, that this is their calculus.
“You know, I could maybe give you ten reasons why this bill shouldn’t be considered,” Iowa’s Chuck Grassley told reporters in his state Wednesday. “But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”
Senators are not supposed to support legislation that they believe to be unworthy of consideration on substantive grounds just because they promised their voters that they would support a bill of that general type. The entire point of having a republic — as opposed to a direct democracy — is that the former enables elected representatives to exercise independent judgement in policy-making.
Still, as contemptible as Grassley’s official rationale for supporting Graham-Cassidy is, his party’s actual motivation for pushing the bill is (almost certainly) more sinister. In truth, Graham-Cassidy does not fulfill the Republican Party’s promises to its voters — and there is virtually no evidence that said voters would punish the party for failing to pass it. The bill does, however, advance the priorities of the GOP’s big-dollar donors — and there is significant evidence that they would punish the Republican lawmakers if the legislation fails.
It’s true that Republicans have spent nearly a decade promising voters that they would “repeal and replace Obamacare.” But most Republicans specifically promised to replace the law with one that would make health-care benefits more generous and universally affordable. Our Republican president promised to preserve Medicaid in its current form and achieve universal coverage with lower deductibles. The mogul even went so far as to explicitly disavow the conservative movement’s traditional hostility to the welfare state, telling 60 Minutes, “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
Trump wasn’t the only one singing such a tune. Virtually all of the GOP’s leading lights attacked Obamacare from the left, including Senate Majority Leader Mitch McConnell, who lamented in January, “There are 25 million Americans who aren’t covered now … And many Americans who actually did get insurance — when they did not have it before — have really bad insurance that they have to pay for, and the deductibles are so high that it’s really not worth much to them.”
McConnell, Trump, and their co-partisans pretended to support a more generous government health program for a reason: That is what most Republican voters want. Earlier this year, a Morning Consult survey found that a majority of conservatives — and a large plurality of self-identified tea-party supporters — thought that “the government should spend more on health care.”
Those findings are consistent with polling from Pew Research, which back in May found 61 percent of Republican voters saying that government funding levels for health care should be maintained or increased. Meanwhile, according to a recent poll from the Kaiser Family Foundation, only 12 percent of all U.S. adults support cuts to Medicaid (which happens to be about the percentage of the public that supported the Senate’s previous Medicaid-gutting, Obamacare-repeal bill).
Graham-Cassidy would cut federal spending on insurance subsides and the Medicaid expansion by an estimated $243 billion between 2020 and 2026. That is neither what Republicans campaigned on, nor what their constituents want.
But it is what their most affluent donors want — or at least they believe it moves the ball in their desired direction. While Republican voters are broadly supportive of Medicaid — and many GOP senators from Medicaid-expansion states have touted their support for the policy — the conservative donor network funded by the oil billionaires Charles and David Koch has been unequivocal in its opposition to the federal program.
“Our network voraciously opposed Medicaid expansion in state after state,” Tim Phillips, head of the Koch-funded nonprofit Americans for Prosperity, told GOP donors at the Koch Network’s June retreat. “These Republicans who expanded Medicaid were flatly wrong. So we’re going to continue holding these Republicans accountable.”
At the same retreat, the Koch brothers themselves complained that the Republican health-care bill — which, at the time, already included significant cuts to Medicaid — was insufficiently conservative. That bill failed, amid widespread public opposition to its austerity. Senate Republicans responded by drafting a new iteration of Trumpcare that cuts Medicaid — and subsidies for health insurance — even more severely.
In voting for Graham-Cassidy, Republican senators might fulfill promises they made to Charles Koch in Colorado Springs. But most would actually be breaking their promises to voters. Multiple GOP senators pledged to vote against any bill that failed to preserve protections for people with preexisting conditions, address the opioid crisis, or reduce insurance premiums.
Graham-Cassidy fails to do all of these things. In fact, its scheme for block-granting federal health-care spending to the states is so haphazard and ill-thought-out, it would lead insurers to drastically increase their premiums, so as to protect themselves against market uncertainty.
The notion that Republicans need to pass a bill that will increase the cost of health insurance — and break a variety of substantive promises to their constituents — for the sake of political expediency is bizarre. The only evidence for this view is that Republican voters still support “Obamacare repeal.” But if GOP lawmakers want to vote for a health-care bill that breaks their substantive promises to voters — and call it “Obamacare repeal” — they have better options.
Days ago, Senate Democrats offered to support waivers that would allow red states to opt out of some Obamacare regulations, in exchange for funding to shore up the exchanges. This legislation would have averted a significant spike in insurance premiums next year — and, in keeping federal funding for health-care constant, it would have been closer to the substantive wishes of GOP voters than Graham-Cassidy is. What’s more, some Democrats were prepared to let President Trump call the measure “Obamacare repeal.”
There is no reason to believe that the GOP’s political interests would be better served by passing a radical bill that will increase health-insurance premiums than by passing a bipartisan one that will reduce them — unless one stipulates that doing the latter would alienate big-dollar donors. Trump voters overwhelmingly approved of the president’s bipartisan debt-ceiling deal — and independents appear to have been even more enthusiastic.
The GOP base is not allergic to bipartisanship and compromise, so long as it’s their champion who’s making the deals. But the Koch brothers are. The Kochs do not oppose Obamacare because the program doesn’t work well enough — they oppose it because they find it morally wrong for the state to take money from wealthy people and use it to subsidize health insurance for non-wealthy people. Thus, technocratic fixes that make government-subsidized health care work better are antithetical to their project. Their interest is not in improving the Affordable Care Act, but in discrediting the premise on which it is based: that redistributive government programs can improve health care for most Americans.
And the Kochs and their ilk have made clear that Republicans who buck them will face consequences. This week, NBC News’ Kasie Hunt tweeted, “Republicans heard loud & clear from donors this August that do-nothing isn’t going to cut it.” At the Koch retreat in June, at least one major donor threatened to close “the Dallas piggy bank” until repeal was passed. In August, one Republican donor responded to the apparent death of Obamacare repeal by actually suing the party for fraud.
Republicans don’t need donations from billionaires more than they need the votes of their base. But the former pay far closer attention to the details of policy. On fiscal matters, it is much riskier for Republicans to buck their donors than to betray the constituents who elected them.
Senate Republicans are on the cusp of radically reforming our health-care system in ways that they do not fully understand — and that industry stakeholders and GOP voters broadly oppose — out of fear that a few dozen obscenely wealthy libertarians will evict them from Congress if they don’t.
If Graham-Cassidy becomes law, our nation will enter a health-care crisis. But the fact that 40-something senators would vote for the bill, today, means that we have already entered a democratic one.