Health care smackdown: Last-ditch repeal drive threatens bipartisan fixes For seven years the GOP has neglected and exploited Obamacare's flaws. But a serious bipartisan effort will show most are easily remedied.

Andy Slavitt | Opinion columnist

Show Caption Hide Caption The entire US will have Obamacare coverage in 2018 but it may not last Every county in the U.S. will likely have a health insurer through the federal marketplace in 2018 after the last county without it got coverage. Video provided by Newsy

While America has been distracted by Russia, North Korea, Charlottesville and Hurricane Harvey, two opposing forces have been gathering steam and are likely to bring the health care debate to an explosive head by the end of the month.

On one side, powerful Republican Senate committee chairs and their Democratic counterparts are leading an effort this week to move health care reform in a bipartisan direction by focusing on small improvements to the Affordable Care Act. This is what the majority of Americans say they want and it hews to what the ailing Sen. John McCain urged in a dramatic speech in July.

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Their push kicked off Wednesday with the start of committee hearings featuring conservative and liberal governors, insurance commissioners and policy experts. In a time of more than enough chaos, the comity alone is reason to applaud.

But not so fast.

There is competition — yet another partisan effort to repeal the ACA, led by Republican senators Lindsey Graham of South Carolina, Bill Cassidy of Louisiana and Dean Heller of Nevada. Though it is out of touch with public sentiment, their proposal has one new thing its sponsors are hoping will make a difference — financial payoffs to the states of senators whose votes they are courting.

The first draft of Graham-Cassidy-Heller looks like the same repeal-and-replace plans Americans soundly rejected in poll after poll. It would end both Medicaid for people slightly above the poverty line and tax credits for people buying coverage in the individual market, replacing both with a capped block grant that would gradually shrink until it disappeared altogether. The plan also makes deep cuts to Medicaid, weakens federal protections for people with preexisting conditions, and introduces Medicaid caps which limit the spending on low-income kids, seniors and people with disabilities.

But it’s not Graham-Cassidy-Heller’s unpopular policies that are expected to make a repeal effort successful. The secret weapon is a cynical redistribution of federal money from mostly urban, blue states that have expanded Medicaid to rural, red states that did not.

An analysis from the Center on Budget Policy Priorities of an early version of the bill estimates what this will mean for states. Nine states would see their funding cut by 50% or more compared to what their Medicaid expansion and exchange subsidies would otherwise be. These states include expected conservative targets like New York, California, New Jersey and Massachusetts, but also North Carolina, Florida and Virginia.

Yet somehow Maine, Alaska, Nevada and West Virginia are almost entirely protected from these cuts in the early years (although every state would be hard hit in the long run or in the event of a recession or public health emergency like Hurricane Harvey.) What do those states have in common? Each has Republican senators who either voted against or strongly considered voting against the last Senate repeal bill.

The repeal effort doesn’t seek to solve the problem of covering more people or making health care more affordable for American families. If assessed by the Congressional Budget Office, it will surely show many millions losing coverage and higher costs for millions more. Instead they are dividing the country into winners and losers (or losers and bigger losers) to achieve a more straightforward goal — finding the 50 Republican votes that, along with Vice President Pence as the tiebreaker, will give them a Senate win.

Graham, who spent some of August in Arizona on shuttle diplomacy, believes the path to success is to appeal to “25 governors” who will make out better under his plan. When the formula for redistributing federal dollars is finalized, my conversations with sponsors suggest, it will reserve discretion for Health and Human Services Secretary Tom Price to adjust the formula as needed to get these states — and their senators — on board.

The ACA, despite President Trump’s efforts to undermine it and scores of congressional efforts at repeal, is surviving. The president’s rhetoric that the ACA was “dead” clearly proved false despite his continued efforts to rob it of needed funding and create uncertainty for its participants.

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The law has helped millions but has its flaws. I have always contended a serious bipartisan effort will show most of the flaws to be easily addressable. But any weaknesses, rather than being addressed over the last seven years, have been neglected and exploited. At each turn, there has been an opportunity to take a bipartisan approach and each time the Republicans have rejected the opportunity. There’s no guarantee that this time will be any different. However, after a public collapse of repeal, there are lawmakers who now appear ready to push in a bipartisan direction.

September will be a telling and busy month in Washington. As lawmakers focus on a budget, a debt ceiling, hurricane recovery and threats from abroad, it may in fact be their approach to health care that is yet again the defining moment for Congress.

Andy Slavitt, a member of USA TODAY's Board of Contributors, is a former health care industry executive who was acting administrator for the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter: @ASlavitt