So why might Cassidy-Graham succeed where other Republican proposals failed? It thrusts responsibility on the states. Federalism has long been a valuable tool for reactionary public officials acting in bad faith. It’s a lot easier to defend an attractive-sounding abstract principle like “state sovereignty” than to defend, say, segregation on the merits. Cassidy-Graham is in this ignoble tradition, shifting the discussion away from policy changes that would be immensely unpopular if made directly by invoking the “flexibility” being given to state governments.
Essentially, Republicans are claiming that many people lack access to affordable healthcare because federal politicians haven’t been creative enough, and allowing the states to experiment will solve the problem.
But this is abject nonsense. The politics of healthcare reform in America are difficult because powerful actors have a vested interest in an inefficient and inequitable status quo. But the policy question is not difficult. Under a market system, many people cannot afford access to basic medical care, and all but the most affluent cannot afford expensive treatment for a serious illness. To get needy people access to healthcare requires some combination of public expenditure and cross-subsidization of the sick by the healthy. (During his brief “Kimmel” phase, Cassidy understood this.)
Though the ACA did not go far enough, it used tighter regulation and more generous subsidies to provide access to tens of millions of people. Cassidy-Graham would destroy this progress. States are no more likely to find a way to provide effective coverage to more people with less money and fewer rules than they are to discover a formula to convert urine into fine Cabernet Sauvignon. It can’t be done.
Supporters of universal healthcare in California and other states that have used the ACA to cover as many people as possible might be tempted to find a silver lining here. Couldn’t states use the increased flexibility to create a single-payer system? Almost certainly not, because the block grants aren’t generous enough. As Sarah Kliff of Vox observes, states such as California and New York would have to spend a lot more money just to retain the coverage levels of the ACA. The “flexibility” offered by Cassidy-Graham is a ruse — it would make it easy for states to cover fewer people but exceptionally difficult for states to cover more people.
If Cassidy-Graham was about giving more flexibility to the LABORATORIES OF DEMOCRACY, it would provide the same money with fewer conditions. What the proposal is actually about is passing massive cuts to healthcare spending and making state governments take responsibility for it, while as a side benefit punishing the states that actually tried to provide coverage to as many people as possible.