Winners and losers under Graham-Cassidy

by on September 22, 2017 at 7:45 am in Current Affairs, Economics, Medicine, Uncategorized | Permalink

…the greatest winners in 2026 would be Mississippi and Kansas, where federal health-care funding would more than triple and double, respectively. On the other hand, Connecticut’s aid would be cut by just over half.


…the Kaiser Family Foundation…concluded that 35 states would lose $160 billion under the bill. The Kaiser study, like two earlier this week, looked at the cumulative effect from 2020 to 2026.

Here is the Amy Goldstein and Juliet Eilperin piece at WaPo.

1 Tom T. September 22, 2017 at 7:48 am

Based on the state’s mentioned, it sounds like a net positive in terms of reducing inequality.

2 rayward September 22, 2017 at 7:57 am

True, if one considers inequality across states rather than within states. It’s like globalization and inequality: globalization has reduced inequality across countries (as between developed and undeveloped countries) but increased inequality within countries (including China, the country that benefited most from globalization). As I commented to the blog entry about music, in the era of globalization what people in America fear is change, and Graham-Cassidy is change on steroids, likely resulting in change in the health care system in every state.

3 Borjigid September 22, 2017 at 8:37 am


4 Mosher September 22, 2017 at 9:07 am

…yes, economic equality was a founding principle of the ‘united states’. How fortunate our Congress so enthusiastically pursues that objective, despite the fiscal bankruptcy of the federal government.
Why are average Americans so fearful of change/progress to the glories of socialism.

5 A Definite Beta Guy September 22, 2017 at 9:25 am

Clearly the Founding Fathers believed in federal mandates to buy birth control. It was in fact the entire reason we rebelled from the King in the first place.

6 wait September 22, 2017 at 11:35 am

Clearly the Founding Fathers believed corporations were people and states shouldn’t recount votes to figure out who actually won the presidency. See I can play your stupid game too!

7 Anonymous September 22, 2017 at 8:18 am

Kind of, but it looks like Cassidy cut himself a raw deal on that front.

LA subsidizing TX?

8 BC September 22, 2017 at 10:30 am

Graham-Cassidy tries to treat all states equally, right? States are awarded funding based on how many people meet certain criteria around income and so forth. If a state is “losing” funding, it’s because it was getting more than its fair share before. It’s a strange argument to say that one should get special treatment in the future because one already received special treatment in the past. If anything, one should be glad that there’s no clawback provision to completely equalize funding over the entire Obamcare plus Graham-Cassidy period.

Graham-Cassidy is hard to oppose because, to do so, one has to argue that states shouldn’t be treated equally and/or that states shouldn’t be allowed to do what they think is best for their own residents.

9 Bob September 22, 2017 at 11:05 am

You use the words Equally and Fair, as if the model that Graham-Cassidy decides for comparison is right. I can generate thousands of different models for state by state fund allocation that don’t look at the name of the state, and get very different results. Therefore, arguing in those grounds alone is extremely easy.

Then there’s the question of whether handing money to states with so few requirements is really good or not, as ‘let the sickest people rot’ is a perfectly legal way of dealing with this. Sorry cancer patients! Need dialisis? Good luck.

I’d argue that going further into a by state model is going to increase the differences in taxes vs remittances in federal spending, and might end up putting us in the road of ‘California becomes Catalonia and decides that sharing with people that want different laws is for losers’, which would not be a great economic outcome.

It might be a fun thought experiment for Tyler though: What if the US moved to a model not unlike of the Confederacy, other than just skipping the whole slavery business. Or go all the way and consider states to be 50 countries that speak the same language and a few shared treaties.

10 BC September 22, 2017 at 12:17 pm

“Sorry cancer patients! Need dialisis? Good luck.”

Why do you believe that the federal government, controlled by Trump and the Republican Congress, care more about cancer patients in California than Californians themselves? Do you just happen to have a really high view of Trump and the Republican Congress?

11 JonFraz September 22, 2017 at 2:00 pm

The CSA was not significantly different from the US on the matter of federalism. Given how Jeff Davis did his best to ride roughshod over the state during his brief few years in office (yes, there was a war on) it’s a pretty good guess a victorious Confederacy would have evolved Big Government just as the US did. Moreover the Southern elite were fair-weather federalists. When it came to runaway slaves they expected the full force and power of the Federal government to override state laws.

12 Ricardo September 22, 2017 at 12:32 pm

“Graham-Cassidy is hard to oppose because, to do so, one has to argue that states shouldn’t be treated equally and/or that states shouldn’t be allowed to do what they think is best for their own residents.”

This statement contradicts itself. Under the status quo, states can decide whether to opt in to Medicaid expansion or not. You defend the concept of states being allowed to do what they think is best for their residents but decry the results in the case of Medicaid expansion as “special treatment.”

13 mulp September 22, 2017 at 3:12 pm

It’s the conservative free lunch argument.

“We demand religious liberty! That’s why your religion must be made illegal for my religous liberty.”

14 mulp September 22, 2017 at 3:36 pm

“Graham-Cassidy is hard to oppose because, to do so, one has to argue that states shouldn’t be treated equally and/or that states shouldn’t be allowed to do what they think is best for their own residents.”

Gov Brownback decided that what was best for his State residents was doctors and hospitals must not be paid for providing health care to the working poor in Kansas because the money comes from a black man in the White House.

Every State got the same amount of money per working poor person under the same rules for every State (100%, then 90%) so Obamacare treats every State equally.

Prior Medicaid law treated California and New York worse than Mississippi for the disabled and infirm needing medical care. The former only got paid 50% by HHS for medical care while Mississippi got about 80% originally, which is what Mississippi still gets today while California and New York only get 53%.

Payments for the same covered medical care by the Federal government for the disabled, etc, are higher in Mississippi than in California and New York even accounting for the higher prices in the latter due to higher cost of living. Drug costs are basically the same nationally and the Federal payment is 53% of that price in NY and CA by put 80% in Mississippi.

Obamacare Medicaid expansion treated every State equally. It’s just that two dozen States refused money from a black man signed law.

15 mulp September 22, 2017 at 4:18 pm

“Based on the state’s mentioned, it sounds like a net positive in terms of reducing inequality”

Yep, it cuts the payments offered to Mississippi and increases them to some States for the sickest most needy patients, but cuts the available payment for workers paid poverty wages in places in all States.

However, Kansas and Mississippi will be able to get more money without accepting it from a black person offering them money on equal terms to all States. But GOP run States that were not racist will get less money because the about 70% Federal share in many will fall, as will the 90% share for working poor.

Basically the justification for this law being better is like saying being paid $5 per hour for 8 hours, as long as you show up and fill in the time card sometime during the day, is better than being paid $10 per hour for the hours you actually work AND being required to start by at least 8am and leave no earlier than 5pm.

16 Actually101 September 22, 2017 at 10:29 pm

The original article makes a lot of predictions based on the assumption that the law in 2026 would be functioning as written. Given the GOP’s behavior towards the ACA, I wonder if there would be a Democratic effort to weaken, sabotage, and otherwise destroy the law so that that Trumpcare comes off as badly as possible. Or, given the utter incompetence of Republicans (who can’t even REPEAL a law, never mind crafting one!), perhaps they won’t need any assistance creating another epic failure.

17 Alan Goldhammer September 22, 2017 at 8:05 am

I think Graham/Cassidy also calls on states to implement systems within two years of passage. This is probably difficult if not impossible as Massachusetts needed four years to implement RomneyCare. One thing Graham/Cassiday will do is free up more money for HHS Secretary Price to be able to continue using charter jets for his frequent travels.

18 mulp September 22, 2017 at 3:08 pm

They must implement systems that comply with rules HHS must write based on the law so it can test whatever system each State creates to see if it qualifies for the block grant.

Ie, a State can’t take a Graham-Cassidy block grant and use it to pay each State based business 50% in tax refunds on profits in order to attract high profit businesses to the State. Ie, a Gov Brownback health care and education plan.

19 Todd September 22, 2017 at 8:14 am

The real story here is that you have to rely on some entity like the Kaiser Family Foundation to guess at what the effects will be, because there is no true CBO score for this legislation. Or any amendment proposal opportunity. And a full 90 seconds of floor debate scheduled. And if it passes the Senate, the House will only have time for a quick up or down vote. No amendment opportunities, or time for debate there, either.

20 Bill September 22, 2017 at 8:30 am

Don’t you love democracy and the committee process which gives everyone the opportunity to comment and amend a bill, rather than having a few members of the same party, without committee hearing, draft and vote on a bill. What happened to regular order?

Let’s Make America Great Again.

21 MOFO September 22, 2017 at 10:37 am

Yes, its a travesty of democracy that so little commentary is allowed/encouraged about such an important change in health care.

Lets hope for some change we can believe in.

22 Bill September 22, 2017 at 12:28 pm

I don’t understand your comment. If you are saying Commentary is a substitute for legislative process that is a joke but no one is laughing. No one knows what to comment on because a bill wasn’t even submitted. But, more importantly, the legislative process can improve things. Commentary is not a substitute, unless, I suppose, it is Fox News Commentary.

23 Bob from Ohio September 22, 2017 at 10:20 am

“CBO score”

Blind faith.

The CBO badly overestimated the numbers for the original Obamacare bill.

But this time they will be right.

24 EMichael September 22, 2017 at 11:31 am

Umm, no they did not. And that is without the imbecility shown by states that elected not to expand Medicaid.

25 Bill September 22, 2017 at 12:29 pm

Bob, You are wrong.

Politifact: “The CBO actually nailed the overall impact of the law on the uninsured pretty closely. It predicted a big drop in the percentage of people under age 65 who would lack insurance, and that turned out to be the case. CBO projected that in 2016 that nonelderly rate would fall to 11 percent, and the latest figure put the actual rate at 10.3 percent.”

You get a Pinnochio.

26 mulp September 22, 2017 at 3:01 pm

He’s referring to the budget estimate on cash paid for Medicaid, where racists refused to take free money from a black man, proving racism Trump’s both common sense and greed. Pun intended.

The assumption that Kansas will get more money assumes Kansas will comply with whatever rules HHS comes up with to get the block grant under Graham-Cassidy, which might end up being rules written by a black woman or brown woman, who knows, because the 2020 start date is impossible to meet given State legislatures in many cases not being in session every year, thus forcing a delay of the law taking effect.

Kansas has been able to get tens of billions for health care for five years, but it has refused to get it from a black man. Unless you believe Gov Brownback hates businesses and wants them to have less revenue.

27 TMC September 22, 2017 at 3:42 pm

So you’ll be sending me my $2500 I was supposed to have saved? Per year?

28 Sure September 22, 2017 at 5:50 pm

Bob is utterly correct. The CBO predicted that last year the exchanges would enroll 23 million Americans. They ended up enrolling 12.7 million. Put another way the CBO mispredicted enrollment by almost a factor of 2. Likewise, they heavily underestimated the number of individuals who would enroll in Mecaid 10 million vs 14.4.

The fact that their very large errors were offsetting is not encouraging for accurate prognostication. If the error bars on the original projection were identical we would expect that 25% of the time they would be wildly under-counting the numbers and 25% they would wildly over-count. Having a coin-flip come up heads is not terribly impressive.

Now you can argue, rightly, that there were many moving pieces and we cannot treat these as independent estimates, but again that drastically reduces our ability to trust their projections.

More importantly, as a doc I have seen precisely piss all change on the many, many fronts Obamacare was supposed to achieve. Projections of reduced ER utilization? Not a change in mine or anyone else’s except maybe to see it go higher. Increases in life expectancy? Not happening, with such positive trendline as exists being higher in non-Medicare expanding states. Better control of chronic diseases? Not by any of the metrics I see; there has been zilch for better blood sugar, A1c, BP, LDL, or any other marker I routinely run on ER patients with chronic conditions. Infant mortality? Unchanged.

I mean we are dumping buckets of money into this for what again? So lower-middle class people can be protected against medical bankruptcy and old people can have lower insurance premiums? So college students do not have to pay as much for student health insurance?

This was supposed to do something other than shuffle a bunch of money around between patients, the government, the insurance companies, and healthcare providers. Instead I cannot name a SINGLE actual metric of population health (not access) that has actually improved significantly and withstands statistical analysis. There are no sharp inflection points anywhere in the data showing me how Obamacare lived up to any of its predictions to improve health.

29 Potato September 22, 2017 at 6:09 pm

Kulak alert.

Someone call Mother Jones and Vox.


30 Bill September 22, 2017 at 6:40 pm

Sure, You can read it all at Bob is not correct. Here is the link, going into all the detail. Now, if your state did not participate, that certainly has an effect.

Of course, if you get your news, and your views, from Fox News, you’se screwed.

31 Sure September 22, 2017 at 8:09 pm

Bill, might I suggest you read your own source, the CBO drastically overestimated the effect of the individual mandate for driving people onto the exchanges. It dramatically underestimated the effect of throwing money at Medicaid. Their forecasting skills would have been better had they gotten either of those correct, instead they made two errors and were lucky enough to have them average out.

Again though, this legislation was supposed to make me less busy. I was supposed to see fewer patients come into my ED without regular primary care. I was supposed to see fewer patients with poorly managed chronic conditions. My patients were supposed to live longer. NONE of that shows up in my or anyone else’s data.

Health insurance just means you don’t go broke off the health bills and, in theory, do not delay early care because you prepaid for healthcare. You show up to my ED and you are treated regardless. If we are dumping trillions of dollars over the decades into this project we really should see SOME improvement in health metrics, at least in expansion states like mine. I am still waiting for those predictions to come true.

32 Bill September 23, 2017 at 8:54 am


Here is the conclusion of the report:

“In January 2016, the nonpartisan Commonwealth Fund published an analysis by New York University’s Sherry Glied of CBO’s forecast of the ACA’s effects. She called CBO’s predictions “reasonably accurate” compared with actual results in 2014.
The gap between CBO’s prediction and reality has widened now that 2016 figures are available for comparison. But Glied also found that CBO’s predictions were closer to 2014 reality than those of four other forecasters — the Obama administration’s own figures, and those of the RAND Corporation, the Urban Institute and the Lewin Group, a health industry consulting firm.
Glied concluded, “Given the likelihood of additional reforms to national health policy in future years, it is reassuring that, despite the many unforeseen factors surrounding the law’s rollout and participation in its reforms, the CBO’s forecast was reasonably accurate.”

The other part, in case you forgot (but if you didn’t you are as disingenuous as others) was that the Supreme Court stuck down the Medicaid expansion, making it optional for the states, and changing a premise of the CBO estimate.

33 Sure September 23, 2017 at 1:49 pm


Again, your own source says that the CBO made two terrible projections. They overcounted exchange enrollment by a factor of two and they undercounted Medicaid enrollment by a factor of two. Getting the uninsurance rate correct was not a reliable prognostication, it was two terrible offsettiing one. Assuming a normal distribution of error means that they will be far less accurate half the time.

But you make a good point about Medicaid expansion was smaller than predicted. The CBO expected the non-expansion states to contribute around 3.6 million individuals to the Medicaid expansion. Thus the CBO predicted that about 7.4 million individuals would enroll in Medicaid from the expansion states. This means, again that the CBO prediction was off by about a factor of 2.

Your source basically goes on to say that other projections were worse, fair enough. But that basically shows us how hard these things are to accurately forecast. If my projections were off by this amount (e.g. how many milligrams of pressors to give a hypotensive patient to get their MAP up to 45 and their systolic up to 75), many of my patients would be dead. Accurate predictions in this area simply are not possible with current information and techniques.

34 Bill September 22, 2017 at 8:15 am

Block granting is such a good idea,

The states are closer to the citizen,

Which is why

We should

Block grant Medicare.

Amend the bill to add Medicare,

And Step Aside.

35 Anon7 September 22, 2017 at 12:46 pm

Good idea! Starve the entitlement beast!

36 mulp September 22, 2017 at 2:48 pm

Yep, then conservatives would be free to give cash to businesses based on how much profit they have, based on highly profitable businesses like Google paying for generous medical plans, and public transit, and so the solution is to attract enough highly profitable businesses that government can cease to exist, except to hand out cash coming from DC.

37 Floccina September 22, 2017 at 5:04 pm

Block grant all money the feds would have spent on healthcare to states on an age-adjusted per capita basis. Including Medicare, Medicaid, and federal employee’s insurance and tell the states that they must cover at least the old, the poor and federal employees.

38 Floccina September 22, 2017 at 5:08 pm

Either that or have the feds take over all medical regulation. It seems to be bad in principle for the states be the primary regulator of medicine while the federal government pays the bills. The feds’ comparative advantage is in collecting taxes because it’s harder to move to a new country that to a new state.

39 Floccina September 22, 2017 at 5:24 pm

In that case, some states might be able to cover all residents.

40 Bill September 22, 2017 at 8:19 am

We’re all losers under the bill. Doctors do not like Medicaid payments; they are more effective lobbyists at the state level. Blue Cross plans are powerful at the state level, and disjointed at the federal level. If you are living and Florida, as a retiree, and the benefits in that state are cut, you move back or move to a state which has better benefits.

This is a perfect world if you want to cream skim and shift costs to others.

That man cave in the basement you planned will be the future home of grandma.

41 dan1111 September 22, 2017 at 8:31 am

“That man cave in the basement you planned will be the future home of grandma.”

Oh, the horror!

42 Bill September 22, 2017 at 8:41 am

I remember sitting in the back of my parents care after visiting my grandmother in the hospital. She had just had a stroke. The conversation between my parents, before there was Medicare, was: How would the brothers co-sign the note for the hospital care and how would they divide the hospital bill among themselves. And, if she got out, how would they take turns taking care of her.

She died in the hospital, so they didn’t have to take her in; they each paid $3,000 for her care, which was about a 1/4 of their yearly income.

Dan, you can never forget what you didn’t experience, but I cannot forget what I experienced.

43 dan1111 September 22, 2017 at 8:48 am

My apologies. Caring for one’s parents at the end of life is a very serious, very difficult thing. The particular sentence I highlighted struck me as funny, but I didn’t intend to trivialize a serious issue that is close to home for many people.

44 Chip September 22, 2017 at 12:24 pm

+1 for showing class on the internet

45 Anon7 September 22, 2017 at 12:54 pm

Because life is supposed to be one long carefree free lunch.

46 Bill September 22, 2017 at 1:15 pm

No, taxes are paying for it and for this entitlement, they are assessed on the wealthy via a tax on unearned income.

The free lunch is the guy without insurance who goes to the hospital and YOU end up paying for it in your insurance for care, had it been administered earlier, would have cost less.

47 Anon7 September 22, 2017 at 1:30 pm

Soaking the rich or mandating care regardless of ability to pay results in the same thing: someone else is stuck paying the bills. (It is a secondary matter whether the total of the bills ends up larger in the latter case, which is not necessarily true.)

48 Bill September 22, 2017 at 2:32 pm

Soaking the rich? Are you kidding. Those are just words picked up from the 1950’s. Look at the change in wealth and income for the top 1% and the cut of capital gains to 15%. The rich have been bathed, not soaked.

Those kinds of words–like soaking the rich–are just words.

Just words repeated by a parrot.

49 mulp September 22, 2017 at 2:43 pm

So, Anon7, are you calling for a mandatory bullet to the brain, or merely the loan of a gun with one bullet for the minute before being dumped in the street, because you have no money?

The free lunch is all the conservatives making the same basic statement in opposition to every solution, and then refusing to propose and convince society to adopt their solution. And you guys are the first and loudest demanding government do something about the problem when you have the burden, whether the homeless guy in the public way in front of your home, or his dead body.

50 Anon7 September 22, 2017 at 4:44 pm

Envy is an ugly passion that has been around since human beings have associated with each other. The richest 1% do not have an obligation to foot everyone else’s medical bills, so to what extent their income has increased is irrelevant, though you of course focus on the individual capital gains tax (conveniently ignoring other taxes on capital) as if that’s the main driver of their increased income or that they owe more simply because they produced more income.

51 Anonymous September 23, 2017 at 12:09 am

You can argue against progressive taxes in their entirety .. but you can’t come up with a flat tax that pays the bills. That’s why every “flat” tax was smoke that blew away once the CBO etc got to score it.

But if you are really dishonest, sure, you can rail against “soaking” the rich anyway.

52 Floccina September 22, 2017 at 5:22 pm

Canada seems to go through the Provinces:

53 Potato September 22, 2017 at 6:18 pm

Replying to Bill,

How much should the middle class pay? I pay over 33% in taxes. 4 months of the year I work for the government at all levels to buy stupid shit. And that doesn’t include property or sales tax. And that doesn’t include the FICA tax that I’m incurring that democrats pretend isn’t out of my pocket. I’m not rich by any stretch of the imagination.

How much more should I pay? Seriously. I work 60 hours a week at minimum, closer to 70. And 15 of those hours are for your nonsense. Now $5 out of every $100 I understand. National defense. Maybe $10 once you throw in FBI and CIA. But that’s astronomically under what they’re doing. Almost every dollar the government gets is for welfare. Almost every god damn dollar. And why? Because people do not want to work? Because people refuse to save money?

54 Bill September 22, 2017 at 6:46 pm


You need to get a tax accountant or tell the truth.

Here is the average tax rate by income:

Income Bracket Lowest Income in Bracket Average Tax Rate*
Top 0.1% $2.2 million 21.7%
Top 1% $434,682 22.8%
Top 5% $175,817 21%
Top 10% $125,195 19.2%
Top 25% $73,354 16.4%
Top 50% $36,055 14.3%
Bottom 50% <$36,055 3.3%

55 Ricardo September 23, 2017 at 8:11 am

Let’s look at 2014. Total taxable income reported to the IRS was $6.8 trillion. Defense spending in that year alone was $596 billion or almost 8.8% of taxable income. Add in interest on the debt and programs for veterans and you are looking at $912 billion or 13.4% of income. Unless you make deep cuts to military spending, spending on veterans or default on the debt, it is not possible to cut the average effective rate to 10%, even before we start talking about the FBI, CIA, DHS, medical care for the indigent (including the nursing home costs of the elderly), etc.

And as Bill points out, you are either including your state taxes in that 33% figure or else you are understating how well-off you are. A middle class homeowner with some combination of children, student loans to pay off, charitable donations and participation in a 401(k) is almost invariably going to pay less than 33% of income to the feds.

56 Slugger September 22, 2017 at 9:30 am

I am always concerned by state to state comparisons since our states are big and far from homogenous internally. My home state, like many others, has one large urban concentration and a lot of more sparsely populated territory. Rather than seeing how Rhode Island compares to Missouri, I would like to see the impact on Des Moines versus Lone Tree.

57 EMichael September 22, 2017 at 11:35 am

Hard to figure out La, but talking about this increased spending in states that elected not to expand Medicaid with ACA dollars paints a very distorted picture.

58 JonFraz September 22, 2017 at 2:02 pm

And if those states wanted extra money they can already expand Medicaid.

59 mulp September 22, 2017 at 2:28 pm

And Graham-Cassidy will be harder to do whatever is required to get the money than simply acting today to get obamacare money.

That Graham-Cassidy is more vague about what is required to get the money from HHS, whatever the rules are must be figured out, implemented in law faster than required for Obamacare when the money only increased, while in this case all the old money goes away on the day you get Graham-Cassidy money IF YOU COMPLY WITH WHAT HHS REQUIRES.

Graham-Cassidy money is not unconditional.

Obamacare called for cutting old Medicaid money if States did not comply with HHS rules for getting Medicaid money, but scotus nixed that part of the law. Why won’t Federal courts likewise prohibit cutting off Medicaid as it currently exists while requiring new State law to get replacement money?

60 Sure September 22, 2017 at 6:12 pm

Right because 11th Circuit totally stopped this dead in its track and the coercion was overturned by a 9-0 majority. Relying on the federal courts to enforce spending changes is pretty harsh. This was literally the first time this sort of shenanigan was EVER held to be unconstitutional – even when the feds changed IRS rules retroactively they gave them unlimited spending powers, when Libby Dole made the national drinking age 21 on pain of removing highway funds the justices did nothing.

Sorry, but a 7-2 seems like an awfully weak surety to base long term financial obligations upon.

61 mulp September 22, 2017 at 2:12 pm

Given Kansas and Mississippi are already “entitled” to tens of billions in funds if they pass Obamacare laws or regulations, they are no better off under Graham-Cassidy that also requires they pass laws or regulations to comply with Graham-Cassidy, but that would mean violating their rejection of jack boot Washington DC dictates, given rejection of Obamacare money has nothing to do with Obama being black.

Note both States can still get tens of billions of money under Obamacare.

This is like saying you will be richer if a white guy drops $20 on the ground and you pick it up, than if a black guy drops $100 on the ground across the street and you refuse to go pick it up.

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