Margot Sanger-Katz at the New York Times has an excellent piece on the pragmatic implausibility of the Cassidy-Graham bill’s desire to let the states do everything on January 1, 2020:
The challenges would fall into two major categories. First, states would need to make political choices about what they want their system to look like. Next, they would need to submit applications, hire contractors and build new systems to run them. Neither would be easy.
The bill would make health care an active, high-stakes political debate in all 50 states. Under Obamacare, states had limited, rather binary policy choices, and even those were hard for state governments to make quickly….
Once states choose a policy approach, they would need to bring it to life. If they adopt a government-run approach, in which people can enroll in a single public health plan, they will need to develop the parameters for that program and put it out to bid. If they select something similar to Obamacare — some sort of insurance market with income-based subsidies — they will need technology systems that allow them to verify people’s eligibility and income, and link state assistance with their insurance purchases.Most states have lengthy contracting processes, in which they must request proposals and review multiple bids before signing up vendors. Those deals would need to be in place before any software building begins.
The bill envisions that states would have complex programs up and running in twenty seven months from the moment the bill is signed. The bill has numerous instances where the Secretary of HHS has to make new rules and regulations. This timeline is ridiculous. I looked at this matter last November:
Any big bill will have major rule making. Any big bill will require insurers to reconfigure and retweak their systems. I worked 70 hour weeks from roughly July 2012 to October 2013 to get my little part of the QHP Exchanges to a point where the user facing chunk was minimally functional. I then spent another six months getting all of the back-end mechanics of directory and network information working cleanly in an operational, no human intervention sense. (I was up 53 of the 60 hours before October 1, 2013 launch date getting the final network directory ready to launch)….
the functional time frame is shorter as any insurance company changes need to have a code freeze at least three months before the open enrollment period for effective testing. We could hold a hundred million claims for the first quarter of20192020 but that would be BAD (TM). So assuming an October 1, 20189 open enrollment period, the insurers need to have their changes in the final test environment by the middle of July which means development specifications for minor changes need to be developed by January…
Twenty seven months is enough time to launch a tweak with a fair probability of success. Twenty seven months is grossly insufficient time to launch new, complex programs.
rikyrah
Feature, not bug, Mayhew.
Spanky
@rikyrah: Seconded. The Republican Party is all about disassembling government, after all.
The Dangerman
I’m missing something. Money would be flowing from Blue States to Red States. Red States will eliminate coverage for preexisting conditions or they will get priced out of the market, and people with preexisting conditions can either roll the dice by staying in Red States or move to Blue States. Since money’s already being pulled out of Blue States, that will further strain the system. Hell, CA will have to put up border stations to keep the Okie’s with pre-existing conditions out and it’s Grapes of Wrath revisited.
Other than being able to call it Trumpcare, to prevent a primary from the Right, and to fuck Blue States, I don’t see why they’re voting on this thing.
dmsilev
Those are, as far as I can tell, the actual reasons. Yesterday, Vox asked several GOP Senators to explain what this bill was and why they supported it, and the answers basically boiled down to “Obamacare is bad, and this is not Obamacare”.
Bill K
@The Dangerman: You are not missing anything. The whole shift of money to the states is a smoke-screen to cover the cuts to overall funding. The only real goal of this bill is to reduce spending so the rich can get a tax break. And – as you said – to f*ck blue states. Everything else is just fluff to make it seem justified. That is why any close examination of the details reveals gaping holes.
hueyplong
We should stop assuming the GOP cares whether the system collapses. They don’t. They just want the money for top shelf tax cuts.
The spin is all ready to go:
(1) Obamacare was about to collapse too
(2) This proves govt never had any business in healthcare. It can’t be done.
(Pay no attention to all those other developed nations.)
HelenWheels
I’m not trying to be critical or pedantic: Is the proper name for this bill ‘Graham-Cassidy’ as I’ve seen elsewhere, or ‘Cassidy-Graham’ as read here? I’m calling my reps and governor’s office and want to use the correct name :) Thanks y’all!
DBaker
Then there is Kennedy (LA)’s amendment restricting states on the ability to adapt a single payer system, without defining what “single payer system” actually means.
I don’t see how the health insurance companies, even though the country would be reverting to the go-go years of the mid-aughts, are remotely on board with this uncertainty.
rikyrah
@The Dangerman:
In the morning thread, I asked for a Frontpager to make it plain:
BlueDWarrior
@DBaker: if you go by who is supporting this bill, they really aren’t. The only people who are full-throated for this bill are the authors and Republican partisans; everyone else is looking at this as a total mess and probably the mechanism to utterly destroy the infrastructure of American Health Care.
But her emails!!!
Is there a reason why we assume that states would even attempt to put in functioning systems with this money? It’s in the form of block grants that as far as I know the only hard restriction for is that the funds not be used for single payer. Is there a mechanism that prevents them from using this cash for things loosely related to health and then cutting state taxes with the freed up funds? It’s what these states essentially do with much of the other block grant funding.
Mary G
If it weren’t for the sick people who would get royally screwed by this shambles, I almost wish they would pass it. The blowback on these bozos would be phenomenal and wave for the Democrats would be a tsunami. Wouldn’t it?
hueyplong
@rikyrah: Kochs are totally bluffing. They’re going to stand still for a possible Democratic majority?
Courage and Republican are two words that should never appear in the same sentence.
What Have the Romans Ever Done for Us?
I work in Federal rulemaking…I’m an economist with DOT. Generally speaking, any major rule has to go through OMB review twice, once at the proposal stage and then again at the final rule stage. This review takes at least 90 days, or three months, in both cases. It then has to be subject to public comment for two months – possibly longer for a complex rule like this. Then, all those tens of thousands of comments have to be analyzed, summarized, and responded to, and the rule revised as needed in response, followed by another round of 3 months of OMB review before publication. In addition to OMB review, which consumes half a year, there are usually one to 4 rounds of internal review – within the implementing Agency – which could be 2 or 3 rounds, but that can be expedited – and at the Department Level, but again can be expedited. Basically there’s an entire year of review for any big rule. That leaves only 15 months to do the actual work of drafting the rule and accompanying required analyses, which has to be done twice, once at the proposal stage and again in response to comments.
Maybe that doesn’t sound like a super duper heavy lift, except that the regulations have to be out in time for the States to have time to build their new system to comply…so in reality the States need a final rule at least a year in advance and probably longer in advance than that. Given that constraint, 27 becomes an impossible timeline – the Agency would have to have a rule ready to go on day one of the signing of legislation that they know virtually nothing about.
The Grand Panjandrum
Here’s your bumper sticker: Without a right to healthcare there is no right to life.
David Anderson
@What Have the Romans Ever Done for Us?: Yep —
Assuming the law is signed on October 1, 2017, CMS would be working at an incredible pace to have a final rule out on everything important on January 1, 2019 at which points the states need to file their applications and get their insurers onboard and built out by July or August to do open enrollment in October 2019.
Good luck with that!
Percysowner
Interesting piece from Vox GOP senators are rushing to pass Graham-Cassidy. We asked 9 to explain what it does.
Basically they can’t explain what it does or how it works or how it makes things better.
Spanky
Arguably not OT, this is an actual WaPo article headline:
Just shaking my head at all the GOP has wrought.
Elizabelle
To the tech savvy here: is there a free (or low cost) Macbook app that would allow me to scan a handwritten letter and fax it out?
Why yes, I am thinking of writing heartfelt letters to the more approachable Republicans to stop this Graham-Cassidy abomination.
Also, FYI, a TED talk some other Juicer put up yesterday. Former mayor of San Carlos, CA [San Francisco area] on the importance of sending monthly handwritten letters to your public servants. Not a bad habit.
WRT Congress: I am thinking a fax with note that original will follow (to congresscritter’s district office) — that way it may be read and logged in faster (and not face a mailing delay from the East Coast to Alaska or Arizona …)
Ruckus
I had to explain this to people when the ACA was passed. They wanted to know why it took so long. They had no concept of the amount of work and what it meant that the states had to build exchanges. And that was at least knowable, unlike this piece of crap. It shows how much congress today knows about actual legislating. The majority haven’t got a clue, primarily because they don’t want a clue, they want to destroy everything. What are the Kochs and Mercers going to do when the economy crashes and people are willing to publicly, loudly talk about and carry out heads on pikes, you know the French solution?
rikyrah
Entire health care industry fights to kill Republican repeal bill
09/21/17 08:40 AM
By Steve Benen
There was a line in a Politico article yesterday that I read twice, because it was such a striking detail about the state of the health care fight: “To date, not one major health care industry or advocacy group has expressed support for the Graham-Cassidy plan.”
That’s not an exaggeration and it’s no small development. Next week, the Senate is poised to vote on overhauling the American health care system, and at this point, the bill’s Republican supporters have managed to persuade no one but themselves. Medical professionals hate the Graham-Cassidy plan, as do hospital administrators and every major patient-advocacy organization in the country. To a very real extent, GOP lawmakers are going up against literally everyone who has a stake in the American health care industry.
And that includes insurance companies.
What Have the Romans Ever Done for Us?
@David Anderson: It sounds like a lot of long hours. I’ve been there, despite what you have heard about lazy do nothing bureaucrats. What chafes the most is that politicians regularly criticizes us for the process taking so long, when they themselves set up the process and all the hoops we are required to jump through. If we just had to write a rule, not seek public comment or anything, it could get out in a matter of months…but nobody wants to jettison public comment. If we didn’t have to do a 12866 compliant economic analysis, small business impact assessment, assessment to determine unfunded mandates (could be a major issue in this case) and other assessments the process would be streamlined. But they’ve decided all those things are a good idea, so we do them. If we don’t the rule gets vacated by the courts on procedural grounds. They could change the rules at any time but they never will.
Ruckus
@What Have the Romans Ever Done for Us?:
They want it both ways. They want to be heroes to their sponsors and they want to fuck over every citizen and be considered heroes for having done that, by the people they just fucked over. Of course that’s been working for them so far.
Repatriated
@hueyplong:
It’s not a completely idle threat. Buying a Republican majority (possibly) sufficient to advance their agenda of massive tax cuts is far more expensive than merely sustaining a sufficient Republican minority to block tax increases. The latter only requires holding enough states (with their relatively inexpensive campaign costs) to gerrymander House races to get a House majority. or having 40 Senators, or the Presidency. (ETA: or a Supreme Court majority.)
This is their test case, to see whether having spent enough to ensure complete Republican governmental control can get them what they want. If it can’t, they either have to spend far more to get an even larger majority, or settle for just maintaining a block against erosion of their present advantaged status.
Scott
BTW, state legislatures, who I presume will need to craft implementing legislation don’t necessarily meet on a continuous basis. Texas legislature next regular session is January, 2019. Unless there is a special session. Which will piss them off since Texas legislators are part time and do work elsewhere.
Repatriated
@Repatriated: One other thing: The Kochs et al may also be taking into consideration whether Russian “indirect campaign subsidies” will continue to be available for them to leverage….
Which leads me to the answer to the question, “What did the Russians want from a Trump Presidency that they couldn’t get from a generic Republian nominee?” What they wanted was a United States that would be friendly to Russian oligarchs who might find they needed a place to go into exile with their ill-gotten gains. Putin won’t live forever, and many among the Russian elites might find themselves on the wrong side of whoever suceeds him.
What Have the Romans Ever Done for Us?
@David Anderson: I really don’t see how they get the economic analysis to come out looking like anything but a disaster if they do it honestly…this rule is going to impose massive costs on society to no discernible benefit.
Another Scott
@The Dangerman: “1) We must destroy Obamacare! 2) This is our last chance to do so! 3) Therefore, we must do it!!”
That’s the underlying reason. The other things you mention are additional “benefit”, but they’re not the reason why.
HTH.
Cheers,
Scott.
J R in WV
@David Anderson:
As a person who spent most of my career working for state government in departments advanced enough to develop custom software I can promise that no state government can roll out something comparable to Obamacare in complexity in less than 18 months.
It would have taken us that long to staff up to begin coding, as current staff is fully engaged working on existing systems. We would need to interview and approve new contractor developers, some of which are wonderfully skilled and some of which can’t hold down a job for more than 18 months anywhere.*
Or to accept an open-ended contract with a money gouging body shop incapable of doing the job given unlimited resources and time… never a good choice, but sometimes required by political reality.
This really is a scam to steal money from everyone with health care insurance ever, and give it to rich people. As well as changing Obamacare into Trumpcare, which will be appropriate, as Obamacare saves lives for everyone and Trumpcare steals money from everyone. The proposers of this legislation should be indicted for corruption.
*I once worked at a major gas transmission company as a contract developer. A fellow contract developer from eastern Europe was theoretically a PhD Math guy, who for months couldn’t get a DB extract report to total what the users knew it should total. So he hardcoded those answers into his report to get a signoff. Guess what happened next month? Same numbers output, escorted out with a box of personal belongings. But he worked there for nearly two years! He tried to get me to “join” him on a big project at Cincinnati Bell, where he had evidently landed softly, so he could get a referral bonus. I wasn’t interested, guess why!
We once hired a developer based upon a phone interview from Bangalore, India. Interviewee was well spoken, little accent, knew the software we were using cold. Had an mildly unusual speech pattern, all his sentences ended with a lift at the end, as if they were all questions. We offered him the job, which was on an interesting and challenging project and would have led to more work on similar tasks. But when he showed up, his speech pattern did not include the pattern that showed so prominently in the phone interview. Also not down with the software tools, lasted 8 days, and I had to fire him.
Two tiny glimpses at the underbelly of software projects with contract staff.
West of the Cascades
@J R in WV: and even if a state really wants to do a program right, and hires a supposedly reputable company to design the software, you can still end up with a fiasco like Cover Oregon. At least we got a clever Lisa Loeb mockery out of it.
Duane
The lousy bastards want to appease their money masters and save their jobs. They don’t worship Satan, Satan worships them.