Senate Republicans are once again just a few votes away from repealing and replacing Obamacare. It's a plan that senators themselves struggle to explain and defend and that emerged on the public stage mere days before an expected vote.
How have they found themselves here again, after their previous repeal bills failed in July? The underlying truth, the beating heart of Obamacare repeal that refuses to let it die, is: Republicans just want to pass a bill, any bill, to say they repealed Obamacare. Whatever standards they've set for their health care plan, whatever promises they made before, don't matter.
The policy is, in a very real sense, beside the point. Republican senators will tell you that themselves, in their own way.
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"If we bring this up on the floor, I think every Republican senator is in play because every Republican senator will be faced with that binary choice," Sen. Ron Johnson (R-WI), one of the bill's co-sponsors, told reporters. "Okay, maybe this isn't everything they want, but the binary choice is: 100 percent guarantee that Obamacare remains in place, and we may have a path to single-payer, versus this choice of federalism, where we start putting the states back in charge."
This bill, authored by Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA), keeps most of Obamacare's taxes (once a deal breaker for many Republicans), turns the revenue into a block grant, and sends the money down to the states with very few strings attached.
The block grant looks like nothing from any bill Republicans considered in late July. Several provisions cross what used to be red lines for Republican senators. Graham-Cassidy cuts Medicaid deeply by overhauling the program's financing and ending the Medicaid expansion. It would allow health insurers to once again charge people higher premiums based on their medical history.
The bill should be untenable for other reasons: Graham-Cassidy promises steep spending cuts to most states, including those represented by Republican senators. It institutes a timeline — states would need to create brand new health care programs by 2020 — that most experts find unreasonable.
Yet Senate Republicans could be just a few votes away from passing it. There is only one red line the GOP is really afraid to cross: failing to repeal Obamacare.
"Apparently no one cares what the bill actually does. That's a tough thing to say, but it is more true than not," one Republican lobbyist told me. "There are so many senators whose public positions in June leave them absolutely no conceivable way of voting for this."
"Yet," this person added, "here we are."
Graham-Cassidy breaks promises on Medicaid and preexisting conditions
If you transport yourself back to the summer, there were two issues on which a critical mass of Republican senators were unwilling to bend: They refused to back deep cuts to Medicaid, at least not without a softer landing and a viable alternative for covering the program's current beneficiaries than the GOP's bills provided; and they would not roll back Obamacare's protections for people with preexisting conditions.
Graham-Cassidy, when you cut through the spin, would do both.
The bill ends Obamacare's Medicaid expansion in 2020, with no "glide path" that Republican senators like Ohio's Rob Portman and West Virginia's Shelley Moore Capito previously demanded. It ends the expanded eligibility for Medicaid that Obamacare created, and even if states tried to reconstruct Medicaid expansion on their own with the bill's block grant, there almost certainly would not be enough money without an impractical infusion of state dollars.
On top of that, the bill fundamentally overhauls Medicaid by placing a federal spending cap on the program. The Medicaid spending caps alone would cut the program's spending by $120 billion, versus current law, by 2026, according to Avalere Health, an independent consulting firm.
For much of the debate, those Medicaid cuts and the end of Medicaid expansion were a nonstarter for many Republicans. That's what Sen. Dean Heller (R-NV) said earlier this year, as he stood besides Nevada Gov. Brian Sandoval and said he couldn't support a bill that Sandoval opposed.
"This is all about Medicaid expansion," Heller said, adding: "It's going to be very difficult to get me to a yes."
He is now a co-sponsor of Graham-Cassidy, even though Sandoval opposes it.
Sen. Lisa Murkowski (R-AK), one of the most closely watched swing votes yet to take a public position on Graham-Cassidy, suggested to me in June that she couldn't support any bill that ended Medicaid expansion.
"I want greater access and lower costs," she told me then. "For instance, if you are going to eliminate Medicaid expansion or even if you're going to wind down Medicaid expansion, that's not increasing access."
As for preexisting conditions, Graham-Cassidy falls short of Republican promises on that issue as well. If states choose to allow it, insurers could once again charge people higher premiums based on their medical history, a practice Obamacare had outlawed.
Cassidy has sought to defend the provision. "The protection is the same," he told CNN this week.
His justification is that the bill requires states, if they seek a waiver from the Obamacare regulation, to describe how they would maintain "adequate and affordable" coverage for people adversely affected by the change.
The problem is, as Vox's Sarah Kliff already documented, that the bill isn't really specific about what those standards actually mean. So it does introduce a degree of uncertainty around how well people with preexisting conditions are protected that the current health care law does not.
"You could stretch the definition pretty broadly of what counts," Chris Sloan, who has reviewed Graham-Cassidy for Avalere, told Kliff. "Maybe you fund a high-risk pool that only allows in some number of people, and that counts. It's a pretty wide space."
Here, again, Republican senators had long pledged they wouldn't touch the protections for preexisting conditions.
"We're not going to do anything to change the current law when it comes to pre-existing conditions, I know which was a big concern with the House bill," Sen. John Cornyn, the No. 2 Republican, said this summer, per the Hill.
That position was supposed to be prevalent throughout the Republican conference.
"I think people understand that's got to be protected, and people understand what happened when the House dealt with it and opened it up, and it's just not something that senators are wishing to do," Sen. Bob Corker (R-TN) said a few months ago.
Axios's Sam Baker flagged some other provisions — notably, additional funding to address the opioid crisis — that senators had previously conditioned their support on but aren't included in Graham-Cassidy.
Lastly, there were the process complaints. No Senate health care bill has gone through the regular order of committee hearings, expert testimony, or markups. The Finance Committee hastily scheduled a hearing for next week, but it was a naked attempt to assuage those concerns from a few key senators rather than an earnest start to the normal legislative process.
The most prominent critic of the process, Sen. John McCain (R-AZ), who has urged Republicans to return to regular order since he helped sink Obamacare repeal in July, seemed to see through the gambit.
The nonpartisan Congressional Budget Office has said it will be unlikely to provide estimates on how many people would have health coverage under the bill or what would happen to premiums, because of the tight timeline. Johnson, who was at one time fixated on having enough information to determine his vote, dismissed the CBO analysis as "a detail."
But Republicans might do it anyway, because Obamacare repeal
Nevertheless, despite all those broken promises, Senate Republicans are pushing ahead and might be within just a few votes of passing an Obamacare repeal bill.
It doesn't matter which bill it is. I asked an aide to one Republican senator this week whether senators actually liked Graham-Cassidy or whether it was simply the last train leaving the Obamacare repeal station.
"Last train," the aide said.
Republicans will be remarkably transparent about this, if you ask them.
"This is not the best possible bill — this is the best bill possible under the circumstances," Sen. Pat Roberts (R-KS) told Vox's Jeff Stein. "Look, we're in the back seat of a convertible being driven by Thelma and Louise, and we're headed toward the canyon. ... So we have to get out of the car, and you have to have a car to get into, and this is the only car there is."
Grassley was even more blunt.
"You know, I could maybe give you 10 reasons why this bill shouldn't be considered," he told local reporters this week. "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."
So when you cut through the salesmanship around state flexibility and the evils of Obamacare, Senate Republicans will tell you right to your face why Graham-Cassidy, a bill nobody had taken seriously until a week ago, might very well pass the chamber in the next few days. They promised to repeal Obamacare, and this is the only Obamacare repeal bill left.
That's it.
Such an abdication of any coherent policy vision has other Republicans in Washington, particularly those well studied in health policy, baffled.
"I think this process with Graham-Cassidy is an embarrassment on top of the previous embarrassments — the cherry on top, if you will," a second GOP lobbyist told me. "A sweeping revision of federal-state roles in and funding arrangements for health care, with one hearing, no markups, no CBO score. Good grief."
"I still believe conservatives and Republicans have strong ideas for improving how health care is financed and delivered," the lobbyist continued. "But will anyone listen to them after this debacle is finally and mercifully over?"