Senate Republicans can't pass an inoffensive healthcare bill -- they need an effective one

Senate Republicans' healthcare bill is far from perfect, and what it does with the individual market may make things worse.

But the Medicaid provisions provide an opportunity for real reform. If implemented as written, it represents an improvement over a very bad status quo.

One positive point is that it would replace Obamacare's Medicaid expansion with an age- and means-tested tax credit. This will allow many of the childless adults who climbed into the Medicaid expansion to purchase better coverage than Medicaid offers. This would also instantly benefit millions of people in states where the expansion was never implemented.

The bill also places much-needed restraints on Medicaid's growth and removes some of the federally imposed obstacles that states face when they try to manage their Medicaid programs effectively. In theory, this should allow the states to maintain both nominal coverage and access to care — the latter being a serious problem for many indigent Medicaid patients that has been exacerbated by the expansion to childless adults above the poverty line.

But there are still two big problems. The first and most glaring is that the Medicaid reforms contained in this bill may never take effect at all. Just how likely is it that a future Congress — in 2021 when the expansion ends, let alone in 2025 when limits would be imposed on Medicaid growth — will just bite the bullet and allow potentially unpopular reforms to go forward?