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1. All the talk about financial winners and losers (and eventually everyone loses $) under Graham-Cassidy misses a core point:
2. Money does not instantly and magically transform into health care. You have to set up systems. Which is hard. Takes time, investment.
(I'm going to dispense with numbering from here on out—because what's the point once you're past the first tweet?)
The ACA was the biggest change in health care in a generation. Implementing it was incredibly complex. Not smooth, at first. Took years.
Graham-Cassidy would be a *bigger* change than the ACA. And not a stable one, either. Two years to make a new system. Finding ends 8y later.
Graham-Cassidy is like taking 50 functioning cars, melting them down into a block of metal, cutting away a third, and handing out 50 chunks—
and saying, here, make a car out of this and drive it around for a few years. Make any car you want! Aren't you happy now?
That's what a block grant is: money without systems to administer it. And a lot of states are not good at building health systems.
Think about the states that turned down the Medicaid expansion but will get a big check now. They don't WANT to expand coverage—they chose!
So what happens to the money they get? They'll cut existing state health funds & replace them with federal $. Say, to fund tax cut for rich.
Policy outcomes mirror who holds power in a society. Almost by definition, the powerful make the policies. Unequal power, unequal policies.
In states where the poor already get screwed, Graham-Cassidy money won't flow to the powerless poor. This is as predictable as gravity.
This was obvious pre-ACA w/ Medicaid eligibility levels, which were set by states. In Alabama in 09, parents had to earn less than *$4,394.* 
This is obvious in the ACA era too—with who expands Medicaid, and also how states implement the ACA.
It's a truism: Policies reflect the priorities of power. State governments—any governments—don't always act in citizens' best interests.
But the backers of Graham-Cassidy elide this. Look at this quote from a Wall Street Journal op-ed. wsj.com/amp/articles/r…
This is just laughably false. Some states are trying to create great health systems. Others—well, others rejected the Medicaid expansion.
So even to the extent that states set up health systems with their temporary G-C block grant funds, there won't magically become altruistic.
And more to the point, many are unlikely to turn those hunks of melted metal into functioning cars. Especially not in *two years.*
This is incredibly tricky stuff. Many states demonstrably have neither the expertise nor the intention.
As @sangerkatz wrote: building health systems from scratch is hard. nytimes.com/2017/09/21/ups…
Along w/ everything else vicious & destructive about Graham-Cassidy, it's unworkable on a fundamental level. It's a bad bill. Let's kill it.
Update: it's now even worse in Alabama. A single parent of 2 earning more than $2,654.60 is ineligible for Medicaid.
