Graham-Cassidy, the GOP’s last health care proposal, explained with a cartoon

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Senate Republicans have been through four different health care proposals to repeal Obamacare, all of which failed to pass. But now there’s one very ambitious proposal left.

Graham-Cassidy isn’t a sexy or descriptive name, but what makes it so radical is how much it deconstructs the existing system.

It brings back preexisting conditions, so insurers can charge sick people more; it gets rid of subsidies to low- and middle-income people to help them buy coverage; and it gets rid of expanded Medicaid, which gives the poorest people coverage. In exchange, Graham-Cassidy gives some of that money to individual states so they can do whatever they want with it.

It effectively redistributes money from states that opted to expand Medicaid to states that haven’t, which tend to be Republican states. (Read Sarah Kliff’s excellent explainer here.)

To explain how this proposal drastically changes the American health care landscape, we made this cartoon:


Let’s say you’re a mom with a son and a daughter, and they are both raising birds.

One day, you realize that many birds aren’t getting enough nutrition.

So you decide to implement a plan. (This plan represents Obamacare.)

First, you realize that the kids are feeding the birds low-quality food. So you make a rule that requires all food being given to the birds meet certain basic requirements.

Then you realize some birds are able to get crumbs, but it’s hardly enough.

So you subsidize their diet by directly giving them additional food.

Still, the most vulnerable birds can’t even get crumbs.

So you offer your kids a deal: You will pay the whole cost to feed these vulnerable birds for 10 years — but after that, the kids have to chip in 10 percent of the costs.

At first, you try to force them to take the deal. But the Supreme Court said they have to opt in to the deal.

Your daughter takes the deal. So her birds, including the most vulnerable ones, are fed.

But your son doesn’t take the deal, despite you begging him to do so.

He doesn’t want you to control how he takes care of his birds, so he doesn’t take your money. So some of his birds continue to go hungry.

This is how current law works

In this scenario, your rules are Obamacare, and the kids represent the states. The federal government is able to provide subsidies to buy health coverage for low- and middle-income Americans, as well as implementing certain standards for insurers, like making sure insurance plans cover basic benefits and not allowing them to charge more to money to sick people.

But the Supreme Court ruled that each state has to opt in to Medicaid expansion, which covers the poorest Americans.

In this example, your daughter represents the 31 states (and Washington, DC) that opted in to Medicaid expansion, which means they get a lot of federal aid to cover low-income people — and that’s helped them lower their uninsured rates.

Your son represents the states that have not opted in. They are mostly conservative states, mostly in the South and Midwest, that have refused federal money to cover their low-income residents.

Let’s see what their father does (Graham-Cassidy)

One day you go on a business trip, and the kids go to stay with their father, who has a different parenting philosophy.

Their father has some problems with this situation you’ve set up.

First off, many more of your son’s birds are going hungry compared to your daughter’s birds. That’s because your son didn’t take your deal to help his most vulnerable birds — but still, their father wants to even the playing field.

Second, he realizes the parents are spending a lot of money to take care of the kids’ birds.

So their father has a plan. (This plan represents Graham-Cassidy.)

First, he ends all of your efforts to help feed their birds.

Second, he lowers the total amount the parents spend on birds.

Then he gives an equal amount of money to his son and daughter — and lets them each decide how to spend it.

But here’s the problem: Your daughter took your deal, so things were going great for her. But her father is taking away that deal and instead just giving her money. And she realizes there’s no way this money could feed as many birds as before.

Meanwhile, your son’s birds get a little more in resources — which is what their father wanted — but it’s still not enough to feed all of them.

When they ask their father why he did this, he says, “It’s unfair that some birds were born into your supervision, son, and others into yours, daughter. I want to even the playing field.”

There’s something else this plan does: It puts trust in your son to properly use the money to take care of all his birds. But you’re not very confident that would happen, because it wasn’t happening before you put some rules in place.

For example, he could just use the money to feed them all gummy worms because it’s cheaper. Or he might not consider the needs of a sick bird that requires expensive special food.

Ultimately, under this plan it looks like fewer birds are getting fed, and the sicker, more vulnerable birds are less likely to get the food they need.

This is what Graham-Cassidy does

In this example, their father’s plan is Graham-Cassidy.

It gets rid of many Obamacare programs, specifically the subsidies to lower-income Americans and the Medicaid expansion, which covers the poorest Americans in states that opted in to the program. And it cuts the total amount the federal government spends on health care.

With the remaining money, the federal government (now represented by the father) pays the states directly so they can use the money as they see fit. This is a popular conservative strategy known as “block granting.” (For more on how block granting affected welfare programs in the 1990s, read Dylan Matthews’s great explainer.)

The proposal also reduces the number of services insurers have to cover, called essential health benefits, so insurers could sell coverage that doesn’t include basic things like maternity care and mental health services. It also brings back discrimination against preexisting conditions, which means insurance companies can charge sick people more money.

The weird logic here

Let’s try to follow the logic under this Republican proposal: One of the reasons they want to give money directly to the states is because it’s unfair that some states opted in to Medicaid expansion and other states didn’t.

In other words, it’s unfair that mostly Democratic states are taking advantage of a great deal in Obamacare, even though a) Republicans have spent years trying to repeal it, and b) their states shouldn’t be taking advantage of this because it’s terrible.

This logic requires Obamacare’s Medicaid expansion to be both good and bad at the same time.

Of course, the much easier solution would be for all states to opt in to Medicaid expansion, which would allow their residents to take advantage of federal aid and decrease their uninsurance rates. But if the premise is that Obamacare is bad, then it leads to proposals like this one, which back into arguments for why it should be passed.

So is it possible Republicans pass this bill in the next two weeks? My colleague Dylan Scott has the four steps that could make it happen.

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