Suddenly, they're back. It now appears Republicans in the U.S. Senate could resurrect repeal and replacement of the Affordable Care Act by the end of the month.
U.S. Sen. John McCain's thumbs-down in the wee hours of July 28 would go from the gesture of the year merely to a fleeting gesture of summer.
The Senate is operating under a procedural maneuver generally known as "budget reconciliation." It allows it to pass Obamacare repeal and replacement by 51 voters, rather than the 60 required to end debate. That procedural authority ends Sept. 30.
Thus, the race is on to pass--outside of regular order that would require committee hearings--this new supposedly more centrist bill primarily sponsored by Republican U.S. Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana.
Senate Republicans must act by Sept. 30 to give conferees something to consider with the House-passed bill, or give up indefinitely and maybe even deign to work with Democrats to fix, rather than end, the ACA.
That House measure, you might recall, was what President Trump called "mean" a few weeks after he ordered Republican House members to stroke his ego with a celebration of its passage in the Rose Garden.
Trump's public health policy? It's simple. He wants to hear about his winning on cable television news programs.
Let's consider the framework of what the Graham-Cassidy bill would do.
Most of the ACA would tool along pretty much as-is until 2020, when Medicaid expansion and federal funding for premium subsidies and cost-sharing subsidies for poor people purchasing private policies on the health-care exchanges would be done away with.
At that point, those programs--or the existing funding levels for them--would be folded into Medicaid block grants to states along with extraordinary state government flexibility for states to do with the money what they pleased.
There would be no more mandate on employers to provide coverage or on individuals to secure it.
Owing to the state flexibility that conservatives generally extol, a state conceivably could use part of its block grant on subsidies for a self-styled health-insurance exchange that would include a "public option," meaning a government-run system.
Conceivably, if not necessary mathematically.
That's because the initial block grants would reward the most conservative states that chose not to expand Medicaid. They would be based on Medicaid-expansion levels and soon converted to a per-capita formula.
Presumably, Arkansas, an innovative expansion state, would start out with a block grant covering what it was spending for Medicaid expansion along with what the federal government was paying to subsidize the state's lower-income non-Medicaid persons buying policies on the exchange.
But from 2020 through 2027, the block grants would be adjusted by a complex formula that, most who understand the formula say, would reduce their amounts to expansion states but reward non-expansion states--like Texas, to cite one that is nearby and wealthier than Arkansas.
The block grants would expire altogether in 2027, but that is only because the 51-vote maneuver requires that all spending authority must be temporary. Graham and Cassidy assure that the grants would be re-upped in 2027.
Trust us ... or whoever is in Congress in 2027, they say.
The bill's greatest political and human vulnerability will be on coverage for pre-existing conditions, which is mandated but not necessarily with the premium protections of Obamacare.
Presumably, the Congressional Budget Office will score this proposal over the next few days and find that--like all other Republican proposals to abolish mandates and devolve federal authority to states--it will cause millions of Americans now with health insurance to be without health insurance.
That's freedom, Republicans say. You can lead a poor person to mandated coverage, but you can't make him drink voluntary coverage.
Late last week Cassidy said the bill has 47 or 48 commitments from Republican senators.
Of course it does. Any bill to repeal Obamacare would get 47 or 48 Republican Senate votes, including, it goes without saying, those of Tom Cotton and John Boozman.
The issue is whether it gets to 50 votes, at which point Vice President Mike Pence would cast the tiebreaking vote--which he was on hand to do in those wee hours of Friday, July 28, until McCain gave him the thumb.
There are 52 Republican senators. Rand Paul of Kentucky insists he's a "no" on Graham-Cassidy because it fails to jerk away all remnants of Obamacare. Susan Collins of Maine and Lisa Murkowski of Alaska would seem to be "no" based on their long-held concern about Medicaid cuts.
If both were "no," and if Paul remained "no," that would cap the bill's support at 49 votes and kill Pence's heroics, even without McCain, who might still be a "no" because there has been no "regular order," but who is unpredictable and really likes Graham.
Something must be done. Graham-Cassidy ... well, it's something.
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John Brummett, whose column appears regularly in the Arkansas Democrat-Gazette, was inducted into the Arkansas Writers' Hall of Fame in 2014. Email him at jbrummett@arkansasonline.com. Read his @johnbrummett Twitter feed.
Editorial on 09/19/2017