Senate Republicans are trying to revive the momentum to overhaul the Affordable Care Act with the Cassidy-Graham proposal. Here are five things to know about the plan and the rush to pass it. (Jenny Starrs/The Washington Post)


One of the most destructive and awful things that Cassidy-Graham would do — and there are a lot of them — is put intense pressure on states to implement a radical transformation of Medicaid delivery to their constituents in only two years. This is widely seen by health-care policy experts as a recipe for chaos.

It turns out that this aspect of Cassidy-Graham has many Medicaid directors very, very worried — even in multiple red states.

I’m told that many Medicaid directors from states with Republican governors privately blessed a statement from the National Association of Medicaid Directors that sharply criticizes Cassidy-Graham as unworkable and deeply destructive.

The NAMD statement argues that Cassidy-Graham, which would end the Medicaid expansion and replace it with block grants to states, starting in 2020, is simply not doable for most of them. The NAMD says that the scope of implementing this change “cannot be overstated,” adding that “the vast majority of states will not be able to do so within the two-year timeframe envisioned here.”

This statement from the NAMD is being widely reported on today, but people are getting crucial nuances of the story wrong. Many have said this statement represents a consensus of all of the Medicaid directors across the country. Not true: When the NAMD puts out a statement such as this, it often reflects what its board of directors says, not any consensus among all of the Medicaid directors. That is the same here. Indeed, the statement says as much in its first sentence.

But in this case, something unique has indeed happened — and it is more damning than this statement first appeared to be.

Matt Salo, executive director of the NAMD, tells me that the organization privately conferred with many Medicaid directors around the country, in advance of releasing this statement. It is politically sensitive for a Medicaid director to differ with his or her state’s governor on a high-profile matter. While some GOP governors have come out against Cassidy-Graham, many others have not, and some have backed it. Given that Cassidy-Graham is a high priority for President Trump and congressional Republican leaders, it is not easy for a red-state Medicaid director to oppose it.

But in this case, Salo tells me, many Medicaid directors from red states privately said they were comfortable with this statement getting out to the public and lawmakers, and in many cases, they eagerly wanted this to happen. Salo emailed me this:

In preparation for the Board’s statement on Graham-Cassidy, we heard from many Medicaid Directors in red states that they were very concerned about the impacts of the legislation and were at the very least comfortable, if not overwhelmingly supportive of sending a message communicating these concerns.

To be clear, this is actually unusual. As Salo explained to me, these statements require affirmation from only two-thirds of the NAMD’s dozen-strong elected board of directors — only eight people — and generally do not represent the consensus view of the nation’s Medicaid directors.

But in this case, many of them, including many appointed by Republican governors, did want the statement’s message out there. That message is encapsulated by these lines from the statement:

How these block grants will be utilized, what programs they may fund, and the overall impact they will have on state budgets, operations, and citizens are all uncertain. Taken together, the per-capita caps and the envisioned block grant would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history. …

The Graham-Cassidy legislation would require states to operationalize the block grant component by January 1, 2020. The scope of this work, and the resources required to support state planning and implementation activities, cannot be overstated. States will need to develop overall strategies, invest in infrastructure development, systems changes, provider and managed care plan contracting, and perform a host of other activities. The vast majority of states will not be able to do so within the two-year timeframe envisioned here, especially considering the apparent lack of federal funding in the bill to support these critical activities.

To understand what this would entail, read this piece by Margot Sanger-Katz, which explains how Cassidy-Graham would require states to essentially rebuild their health-care systems from scratch. As Sanger-Katz notes, this would instantly “make health care an active, high-stakes political debate in all 50 states,” and in any state that failed to realize this formidable challenge, “consumers and markets would be thrown into chaos.”

It turns out that the people who would be tasked with implementing these radical changes — including many appointed by Republicans — share this view. The question is whether that will weigh on the few remaining undecided GOP senators. It should — if they care in the least about the real-world consequences of their votes.

* MUELLER’S SCRUTINY OF FACEBOOK’S ROLE INTENSIFIES: Facebook has announced that it will turn over to congressional investigators thousands of ads covertly bought by Russian agents, and the New York Times notes this:

One question for [special counsel Robert S. Mueller III] is certain to be whether the Russian Facebook advertising — and any other promotions using Twitter or other services — showed evidence of the kind of sophisticated targeting that might indicate that Americans had provided assistance. Facebook has said some of the ads were targeted to particular geographic areas but has not given details.

Facebook has given Mueller detailed data on the ads, the Times notes, meaning that we will get an answer to that question soon enough.

* TAX CUTS BASED ON PHONY GOP MATH GAIN MOMENTUM: The Post reports that the White House push for enormous tax cuts is gaining momentum among Senate Republicans, and you’ll be shocked to learn what’s driving it:

There is a growing willingness within the GOP to embrace controversial, optimistic estimates of how much economic growth their tax plan would create. Those upbeat estimates, often rejected by nonpartisan economists, would supplant the traditional forecasts offered by official scorekeepers at the Congressional Budget Office and Joint Committee on Taxation, helping lawmakers argue that the plan would not increase the national debt.

Of course, Republicans have been willing to embrace such “controversial” estimates for decades, so nothing new here.

* MURKOWSKI MAY BE LEANING AGAINST CASSIDY-GRAHAM: The Hill reports that Cassidy-Graham’s chief sponsors are leaning hard on Sen. Lisa Murkowski (R-Alaska) to win her vote, but it may not be working:

Right now it looks like an uphill battle to change Murkowski’s mind. “I’d say the chances are less than 30 percent. Alaska doesn’t do very well in this bill. Her governor is lukewarm on it and her insurance commissioner is not for it,” one Senate GOP aide added.

Imagine a U.S. senator putting the interests of her own state over President Trump’s megalomaniacal desire to humiliate Barack Obama!

* GOP GOVERNOR TEARS INTO CASSIDY-GRAHAM: Brian Sandoval, the Republican governor of Nevada, tore into the central rationale of Cassidy-Graham in a statement to the Nevada Independent:

“Flexibility with reduced funding is a false choice,” Sandoval said in the statement. “I will not pit seniors, children, families, the mentally ill, the critically ill, hospitals, care providers, or any other Nevadan against each other because of cuts to Nevada’s health-care delivery system proposed by the Graham-Cassidy amendment.”

The grant of “flexibility” to states is mainly cover to sell its gutting of health-care spending on poor people. And Sen. Dean Heller (R) of Nevada, which stands to lose up to $2 billion, is fine with that.

* GOP IS SELLING CASSIDY-GRAHAM WITH THE SAME OLD LIES: Paul Krugman looks at all the evasions and lies Republicans are peddling to sell Cassidy-Graham and notes that they have been “standard GOP operating procedure for years”:

The trick of converting federal programs into block grants, then pretending that this wouldn’t mean savage cuts, was central to every one of Paul Ryan’s much-hyped budgets. The trick of comparing dollar numbers over time to conceal huge benefit cuts has … been around since the 1990s. In other words, Graham-Cassidy isn’t an aberration; it’s more like the distilled essence of everything wrong with modern Republicans.

It’s odd that these courageous ideological warriors constantly feel the need to lie about the real-world consequences of their policies. Don’t they have confidence in their ideas?

* JIMMY KIMMEL IS RIGHT, AND BILL CASSIDY IS LYING: Linda Qiu and Daniel Victor take a hard look at the ongoing exchange between Jimmy Kimmel and Sen. Bill Cassidy (R-La.) over the latter’s health-care bill. Kimmel is right, and Cassidy is lying, about the bill’s deep cuts to health-care spending and its weakening of protections for people with preexisting conditions.

As Kimmel put it, “I did my homework.” Too bad the bill’s chief co-sponsor didn’t — or if he did, too bad he can’t stop lying about what it would actually do.

* AND IT’S THE ‘DOTARD’ VS. THE ‘MADMAN’: Good morning, Mr. President:

This is apparently a response to Kim Jong Un’s statement blasting Trump as a “mentally deranged U.S. dotard.” Schoolyard taunts are especially awesome when those exchanging them also possess the firepower to slaughter millions with great ease.

Go to Source

Red-state Medicaid directors sound the alarm about Cassidy-Graham – Washington Post