By promising "I will not vote for a bill that will make things worse for Alaskans," Sen. Dan Sullivan has set the bar for health care legislation at a record low level.
Better for Sullivan to declare that he will not vote for a bill unless it makes things better for Alaskans.
It won't be as easy as a campaign pledge, such as Sullivan's 2014 call for "freedom-based" health care solutions.
The Congressional Budget Office said Monday that about 22 million people would lose coverage under the Republican health plan.
The Center on Budget and Policy Priorities estimates that Alaska could fare worse than any other state under the Senate plan because of the reduction in tax credits, Medicaid cutbacks, the low population and the high cost of care.
It will be hard for Sullivan or anyone else to argue that a plan that cuts Medicaid by hundreds of billions of dollars, while granting hundreds of billions in tax cuts for the richest of the rich, is a big plus for Alaskans.
The $33 billion in tax cuts for the 400 wealthiest families in the United States would be about as much as the federal government would otherwise spend on Medicaid expansion in Alaska, Arkansas, West Virginia and Nevada during the next decade.
The Senate bill would end the Medicaid expansion program, which Sen. Lisa Murkowski told legislators in February she would not support.
"I will not vote to repeal it," she said.
Murkowski told CNN Monday she has not seen enough to say she supports the Senate bill, but didn't say she opposes the measure.
"I don't have enough data in terms of the impact to my state to be able to vote in the affirmative," she said.
There has been misleading national press coverage on a provision slipped into the Senate bill that some reporters have dubbed the "Klondike Kickback" — claiming this language is aimed at winning Murkowski's vote — which is wrong for a couple of reasons.
First and foremost, the Klondike is not in Alaska. It's in Canada.
Second, the provision would not be a great boon to the Medicaid program in Alaska or any other rural state. Not applying an additional penalty for Alaska and four other Western states with small populations is hardly "engineering a special deal for Alaska," as a New York Times reporter put it.
Far more than this or the end of the Medicaid expansion, the most far-reaching consequence of the Senate plan would be a structural change to shift more and more of the Medicaid burden to the state.
Alaska and other states with high costs and small populations are the most at risk under this approach.
It could mean billions of dollars in added costs for the state over time, requiring new state taxes or reductions in services to one-quarter of the Alaska population, from kids to residents of the Pioneer Homes.
Medicaid is structured so that the federal government pays a percentage of the costs. This means that when expensive new drugs and treatments become available, when epidemics occur or when the economy declines, the federal government picks up a greater share of the expense.
The GOP Senate plan would cap federal Medicaid payments and allow them to rise only with the general rate of inflation over the long term, which is lower than health care inflation. More and more of the burden would be shifted to the state.
Murkowski and Sullivan have a chance to explain whether they would rather that the state raise taxes by hundreds of millions of dollars per year or reduce Medicaid benefits to tens of thousands of Alaskans.
Columnist Dermot Cole can be reached at dermot@alaskadispatch.com.
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