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Bad health care bill, again 

Wait! Postpone tax reform and everything else for a while longer because the Senate is going to try to repeal and replace the Affordable Care Act one more time before September ends and while it can do it with the votes of only 50 senators.

If it happens, this vote will be particularly meaningful for Arkansas and its two senators, because the Graham-Cassidy bill, as it is called, would be unusually destructive to Arkansas medical providers, the state government budget and, if anyone cares, more than 350,000 low-income people who depend upon Obamacare for their medical care.

In the Washington climate where everyone's motives are suspicious, you still have to assume that the Deep South senators Lindsey Graham and Bill Cassidy are serious about making their bill the law rather than just showing up President Trump again by giving him the one more chance to repeal Obamacare that he demanded after an entire spring and summer of failures. Graham has been Trump's most acerbic critic, but, conceivably, he genuinely wants his bill to become law, although he ridiculed similar bills before voting for them.

The repeal-and-replace campaign provides history's finest burlesque of an old legislative stratagem: Most lawmakers need politically to vote for a bill but do not want it to actually become law, because then they would have to live with the consequences of their act. Republicans in both the Senate and House of Representatives got numerous chances to vote against Obamacare, but despite the GOP majorities not one of the bills reached Trump's desk although he had endorsed every one of them. A changing combination of senators or congressmen lined up on each roll call to block repeal and replace.

Don't confuse Graham-Cassidy with the bona fide but futile effort by Sen. Lamar Alexander, R-Tenn., and a handful of others, including Democrats, to draft a bipartisan reform of Obamacare that shores up shaky markets, assures funding of out-of-pocket costs and gives hospitals, other providers and people with pre-existing conditions some peace of mind. They could add a sentence saying the Affordable Care Act is hereby repealed and Trump would endorse it.

Graham-Cassidy does all the things that Republican senators or congressmen said made the other bills unacceptable—15 million or more people without health insurance, higher premiums especially for people with pre-existing conditions and big reductions in federal support for medical programs run by the states.

The feature that is supposed to make it popular with Republican governors and state legislators turns federal health support into block grants to the states. That is supposed to mean greater "flexibility" for the states. The problem is that you have more flexibility to spend fewer federal dollars. Many states would either have to raise their own spending sharply or else curtail medical services for some or all classes of recipients — nursing home patients, children, the severely disabled, the blind, pregnant women.

Nearly 1.2 million Arkansans — 36 percent of the population — receive Medicaid services each year. Arkansas has one of the unhealthiest and poorest populations in the country and counts more on Medicaid than all but a couple of states.

Graham-Cassidy targets typically Democratic states that exercised the option of extending Medicaid to poor working and childless adults and that also took steps to help low-income people navigate the complicated insurance market and choose an affordable health plan. But Arkansas is a Republican state that came up with its own plan to extend coverage to poor adults, though it never did much to help people get insurance if they didn't qualify for Medicaid. The legislature blocked $10 million of federal help to get people enrolled in an affordable plan.

Arkansas, including Governor Hutchinson and the Republican legislature, would get a severe strapping from Graham-Cassidy. It would take away the billions of federal dollars that has overmatched Arkansas's puny contribution since 2013 and paid for income tax cuts and spread that money among states that did not cover poor adults. Arkansas would be back to 2013, but without billions of federal help and with more than 300,000 poor people still expecting medical assistance.

So how will Sens. John Boozman and Tom Cotton vote? Boozman voted for the other repeal-and-replace proposals and Cotton mixed and matched his votes without explaining why he voted for one and not another. Governor Hutchinson will surely send word privately, please, do not vote for the bill.

Majority Leader Mitch McConnell says he'll make room on the empty Senate calendar for debate and a vote on Graham-Cassidy if they can show him they have 50 votes, which with Vice President Pence's vote would send it to the House of Representatives. It seems to violate the terms of at least a half-dozen GOP senators, but these are crazy times.

If it doesn't become law, neither Boozman nor Cotton needs to worry about his vote. Voters do not hold politicians accountable for simple deceit, but they are liable to get mad if it actually affects their lives and they can figure out who did it.

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