title:  Medicaid Directors Of All 50 States Issue Joint Statement Slamming GOP Health Bill
text: On Thursday, the National Association of Medicaid Directors sent Congress a devastating letter about their planned overhaul of American healthcare. The NAMD is an organization comprised of quite literally every single Medicaid chief in the country, and any statement issued by the entirety of its body is a rare thing. Ironically, the Trump era seems to have ushered in more than one situation in which there is unanimity in opposition to his policies and positions.Medicaid directors are appointed by state governors, which means that the office is filled by partisan picks. Fully 34 of the 50 states, in fact, have Republican governors, so the joint statement isn t just bipartisan   it s almost hyper-partisan.That makes this sharp criticism of the Graham-Cassidy bill even more poignant:BREAKING: The bipartisan Medicaid Directors from all 50 states just issued this negative statement about Graham-Cassidy.Big. Very unusual. pic.twitter.com/ZtqaAI8hg1  Andy Slavitt (@ASlavitt) September 22, 2017That tweet is clickable, and each image in the tweet is clickable, but here are the important parts, in case you don t feel like popping over to Twitter. The bill makes some major changes to Medicaid funding, including a massive transfer of funds from  blue  states to  red  states, and a transition to  block grants  that do not account for increased membership in Medicaid programs. That is to say, states would get the same fixed amount of money no matter how many people signed up, making states with high membership among those with the lowest per-patient allowance. Taken together, the per-capita caps and the envisioned block grant would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country s history. The scope of this work, and the resources required to support state planning and implementation activities, cannot be overstated. States will need to develop overall strategies, invest in infrastructure development, systems changes, provider and managed care plan contracting, and perform a host of other activities. The vast majority of states will not be able to do so within the two-year timeframe envisioned here, especially considering the apparent lack of federal funding in the bill to support these critical activities. With only a few legislative days left for the entire process to conclude, there clearly is not sufficient time for policymakers, Governors, Medicaid Directors, or other critical stakeholders to engage in the thoughtful deliberation necessary to ensure successful long-term reforms. The mostly-Republican board of Medicaid Directors also took the GOP to task for trying to pass this bill before getting a score from the non-partisan Congressional Budget Office. Usually, that s the minimum a bill must have to even be considered for a vote. But Republicans are attempting to pass this bill before the end of the month, since that s the cutoff for them to do so with a simple majority. The Senate parliamentarian ruled that budget reconciliation, the process by which bills can be passed with a simple majority, expires at the end of Fiscal Year 2017. After September, votes will once again be subject to filibusters, meaning Republicans will need to muster 60 votes for anything they want to pass, unless they take Donald Trump s advice and invoke the  nuclear option  in the Senate.That s unlikely to happen, and Republicans are more desperate than ever for a win in Congress. That makes Graham-Cassidy a real danger to the future of American healthcare, despite this damning letter from the NAMD, and despite the massive opposition to the bill by every medical association, most states, nearly all consumers, and even some Republicans.Buckle up, my friends. This could get ugly.Featured image via Alex Wong/Getty Images