Graham-Cassidy is the worst of all of them

I have spent the bulk of 2017 writing about the different Republican plans to repeal the Affordable Care Act.

Graham-Cassidy, in my view, is the most radical of them all.

While other Republican plans essentially create a poorly funded version of the Affordable Care Act, Graham-Cassidy blows it up. The bill offered by Republican Sens. Lindsey Graham and Bill Cassidy takes money from states that did a good job getting residents covered under Obamacare and gives it to states that did not. It eliminates an expansion of the Medicaid program that covers millions of Americans in favor of block grants. States aren’t required to use the money to get people covered or to help subsidize low- and middle-income earners, as Obamacare does now.

Plus, the bill includes other drastic changes that appeared in some previous bills. Insurers in the private marketplace would be allowed to discriminate against people with preexisting conditions, for example. And it would eliminate the individual mandate as other bills would have, but this time there is no replacement. Most analysts agree that would inject chaos into the individual market.

Taken together, these components add up to a sweeping proposal sure to upend the American health care system. Because the Senate hasn’t seen an independent analysis yet from the Congressional Budget Office, I can’t even say for sure how sweeping, and neither can any of the Republicans who have come out in support of it.

’m not the only one drawing this conclusion. The credit agency Fitch Ratings recently described Graham-Cassidy as “more disruptive” than the other Republican repeal bills. Edwin Park, a policy analyst at the Center on Budget and Policy Priorities, says that Graham-Cassidy is “more radical in the sense that you’re eliminating wholesale the marketplace subsidies and the Medicaid expansion.”

Robert Laszewski, a health consultant who is generally critical of the Affordable Care Act, says that “passage of this bill would create enormous market uncertainty.”

The Graham-Cassidy bill has, so far, received far less attention than the last bill the Senate considered in July or the one the House took up in May. But the reality is that this quiet bill would be far more disruptive.

Graham-Cassidy introduces an entirely novel funding mechanism for distributing this funding: moving money from states that have worked aggressively to expand coverage to those that have made little effort at all. It creates a funding formula that is meant to give states “more equal” health care funding, tethered to the size of their population.

Perversely, this punishes the states that have expanded coverage the most, either by expanding Medicaid or by getting a lot of people signed up for the marketplace (and thus have higher marketplace subsidies flowing into their state).

This, again, is something we do not see in the other Republican bills. No other bills contemplated simply taking money from Ohio, which expanded Medicaid, and sending it to Virginia, which didn’t.

Look, for example, at what happens in Florida, a state that hasn’t expanded Medicaid but has worked diligently to get its residents enrolled in marketplace coverage. Florida has signed up more of its Obamacare-eligible residents for coverage than any other state. It has the biggest marketplace in the country, and its residents received $5.8 billion in Obamacare tax credits in 2016.

What reward does Florida get in Graham-Cassidy for expanding coverage so dramatically? A $2.6 billion budget cut. And again, this happens specifically because Florida has signed up so many people for Obamacare coverage and thus its residents receive a generous amount of health law tax credits.

The idea of expressly cutting funding for states that have done the best at getting their residents coverage doesn’t show up in any other health care plan except Graham-Cassidy.