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Opinion | Jon Kingsdale

Latest health care bill is legislative malpractice

Senator Bill Cassidy, Republican of Louisiana, spoke Sept. 19 on Capitol Hill.
Senator Bill Cassidy, Republican of Louisiana, spoke Sept. 19 on Capitol Hill.Alex Brandon/Associated Press

In a last-ditch effort to repeal the Affordable Care Act, Republican Senators Lindsey Graham and Bill Cassidy are offering a policy mirage. They propose repealing the ACA and giving much of the ACA’s federal funding to the states, to use for medical coverage as each state decides.

This 11th-hour ploy constitutes gross legislative malpractice. Strong language? No, Cassidy-Graham would be a fiasco-for-all, even by conservative standards.

Conservatives may dismiss as liberal cant the critiques that apply to this and their previous repeal and replacement bills – millions more uninsured, abrogation of consumer protections, and gutting federal subsidies for Medicaid. Vindictive Republicans may consider it justifiable political retribution to re-allocate federal subsidies from states, such as Massachusetts, that have done the most to cover the uninsured, in favor of red states.

But Cassidy-Graham will sow havoc across the political landscape. It gives the states less than 24 months to develop their reform concepts; explain them to voters, insurers, and providers; agree among the legislating branches on one approach; gain approval from the federal government; raise needed state revenues; and then implement their plans. Without the ACA’s market rules, mandatory participation, directed subsidies, and federal exchange, there’s no default option for those states that cannot shoulder this heavy political lift.

As someone who helped implement “Romneycare,” and has helped a dozen other states wrestle with the ACA, I shudder to think of each state starting over from scratch.


Consider, for example, our own near-universal coverage reform. Massachusetts began in 2003 with a series of studies and public forums, sponsored by the Blue Cross Blue Shield Foundation. By 2004, an approach had been vetted and public support for it was beginning to build. Governor Romney adopted that approach, offering his proposal in the spring of 2005. A coalition of consumer advocacy and provider groups threatened to mount a ballot initiative campaign if the State House did not act, and still it took another year to enact the law.

But that’s only part of the timeline. Our reforms took another 15 months to implement — from Mitt Romney and Ted Kennedy’s famous signing celebration in April 2006 to opening the Mass. Health Connector’s third individual insurance program in July 2007.


Fifteen months to implement was considered very aggressive, and we did it only because the reforms enjoyed overwhelming bipartisan support from voters, politicians, and stakeholders alike. Graham-Cassidy would allow the states less than 24 months to do it all.

And even if some states meet this deadline, how many of them will have a functioning exchange repealed, only to discover that the replacement doesn’t work? Three and a half years after president Barack Obama signed the ACA (in 2010), Massachusetts fumbled the roll-out of our re-formulated Connector. Not until 2015 did it work properly. The federal government and many other states encountered major “glitches” rolling out their exchanges, too.

Rearranging our medical economy, which makes up 18 percent of GDP, state by state is not a two-year task.

Actually, the fallout from this legislative malpractice may hit far sooner. Just the prospect of such disruption may frighten off private health plans. Within six to nine months, they have to file premium rates for 2019; which among them wants to be the last one in the individual marketplace for a state that has designated no viable replacement, let alone field-tested it?

To Republicans in Congress, inclined to dismiss such practical concerns, I offer one last piece of evidence: After seven years, the best you can come up with is to punt the whole mess to the states. Really?

Legislative malpractice is an understatement.


Jon Kingsdale is associate professor of the practice at Boston University School of Public Health and a health strategy consultant.