Once More Unto The Breach
The 115th Congress opened with a concurrent resolution which was clearly intended to allow the use of Budget Reconciliation to repeal Obamacare but, with the Fiscal Year set to close at the end of the month, congressional Republicans have been unable reach consensus on the issue. With the clock running out on the GOP’s seven-year crusade to repeal the bill, the Cassidy-Graham amendment is the party’s latest, and likely last, attempt to deliver on that promise. Like most projects left to the last minute, the Cassidy-Graham plan is mostly smoke and mirrors, seeking to deliver on a repeal while avoiding the political costs associated with one.
Why this matters
The Congressional Budget Office suggests that repealing the ACA would make tens of millions of Americans lose their health insurance. Rather than take responsibility for that Cassidy-Graham passes the responsibility to the states, charging them with running their own insurance programs and leaving patient health at the mercy of chronically underfunded state budgets.
Cutting Medicaid outright was a political non-starter for Senators from states that had taken the Medicaid expansion under the ACA. Rather than for them to own the cuts, Cassidy-Graham takes the funds allocated to the Medicaid expansion and divides them as block-grants to the states. The result is that states which took Obamacare dollars will see massive cuts while those that did not will get large checks, at least early on. With time Cassidy-Graham tapers off that funding until it vanishes in 2026. Consequently the plan calls for a slow drop off over the timeline typically scored by the Congressional Budget Office with a massive cut in 2027.
Unfunded, left to weak state governments, and thrown out of the national spotlight, the Cassidy-Graham plan would see the ACA wither on the vine in an attempt to render an appeal more politically palatable. As Senator Graham told CNN “if you like Obamacare you can keep it.” But the devil, they say, is in the details.
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The Federal fiscal year ends on September 30th and with it the budget resolution that allows the GOP to use “reconciliation” to push a bill through the Senate with a 51 vote majority. Reconciliation is an arcane procedural trick of Congress but it’s also very limited. To invoke it, Congress has to pass a budget resolution (tricky) and then, in that resolution, instruct one or more committees to “reconcile” the tax code with their mandatory spending priorities. But there’s a catch, Congress can only use reconciliation once on spending, revenue, and the debt-limit per budget resolution. That means that once Congress passes, under reconciliation rules, a bill that affects one-cent of government spending no other bills which affect spending can be passed under reconciliation rules until there’s a new budget resolution. In theory this means reconciliation can be a three-strikes process, but in practice it’s difficult for Congress to keep spending and revenue so separate.
In truth, Congress could very well adopt a new budget resolution on October 1st instructing the committees to take a second run at repealing the ACA. With midterms coming up in 2018, however, there is the possibility of losing control of at least one chamber should President Trump’s unpopularity translate into high Democratic turnout. Rather than spending all of their time trying to repeal a popular program, the 115th Congress will likely want to use reconciliation in the 2018 fiscal year to push through tax cuts. As a consequence, while September 30th is not a deadline for repeal in any legal or rules based sense, it is a de facto one.