In both its substance and its procedural details, the plan cooked up by the Trump administration and House Republican leadership to overhaul the American health care system is completely insane.
As of Thursday evening, Republicans have announced a plan to stage a do-or-die vote on the legislation to repeal the Affordable Care Act and replace it with a new system. They’re not sure they have the votes to pass the bill, in part because the actual substance of the bill was only coming out at around 9 pm. With the text finalized so late, they won’t have analysis from the Congressional Budget Office before the planned vote.
What we do know is that the bill is unpopular — with a favorable rating of 17 percent according to a Quinnipiac University poll — and that it can’t pass the Senate without either substantial modification or a whole bunch of senators very suddenly dropping major objections to anything that causes so many people to lose their insurance coverage.
But House Republicans are in such a hurry to pass an unpopular bill that won’t become law that they won’t even take the time to figure out what the law does.
AHCA 1.0 meant 24 million people lost insurance
What we do have is a CBO score of an earlier version of the bill, which said it would cause 24 million Americans to lose health insurance while raising premiums and deductibles for remaining patients on the individual market. It would also accelerate the bankruptcy of the Medicare Trust Fund, all in pursuit of a large tax cut overwhelmingly tilted toward millionaires.
That bill, as written, was too right-wing to pass the Senate, where a number of Republicans have raised concerns about the defunding of Planned Parenthood and draconian cuts to Medicaid.
But that wasn’t right-wing enough for the right wing of the House GOP caucus, so now changes are in the works to eliminate federal regulations that require plans on the individual health insurance market to provide “essential health benefits.” (The bill would instruct states to set such regulations on their own.) Those federally mandated benefits, which members of the House Freedom Caucus find so irksome, are as follows:
- Outpatient care without a hospital admission, known as ambulatory patient services
- Emergency services
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services, including counseling and psychotherapy
- Prescription drugs
- Rehabilitative and habilitative services and devices, which help people with injuries and disabilities to recover
- Laboratory services
- Preventive care, wellness services, and chronic disease management
- Pediatric services, including oral and vision care for children
It’s easy to demagogue the idea of removing those regulatory protections. The specter of an all-male meeting deciding that there’s no need for pregnancy, maternity, and newborn coverage is particularly egregious. But many of these line items simply test the conceptual limits of a health insurance plan. Suppose you bought something called health insurance that didn’t cover emergency services, hospitalization, preventive care, or rehabilitative services. Would that even be health insurance?
Worse, neither the authors of the revised legislation nor the members of Congress being asked to vote on it have any idea what the revised bill’s effects would actually be. There are a lot of moving parts to legislation. Will this deregulatory drive make total spending go down (because skimpier plans will be cheaper) or up, because cheaper, skimpier plans will attract more customers who are spending the government’s money? I’m not sure, and members of Congress aren’t sure either. Unlike me, Congress has a team of experts at their disposal who could figure it out for them if they had a few days to work. But House GOP leaders don’t want to know — they’re desperate to hold a vote tomorrow before any analysis is done.
Rush to nowhere
That’s the fundamental insanity of running headlong toward a floor vote without a score from the CBO. A lot of pixels have been spilled on the basic hypocrisy of the procedural aspects of the AHCA. But the real issue here is about substance, not process. Making public policy is hard. The CBO is a tool to help make sure members of Congress understand what they’re doing. They are not using that tool, and consequently, they are flying blind — voting for a series of interlocking changes that will drastically impact tens of millions of people’s lives with no idea what is going to happen.
Most egregiously of all, at this point the tempo is apparently being dictated by Donald Trump’s personal pique at recalcitrant House members.
A president with no interest in the details of public policy is impatient with the idea that House members might care what the content of the bills they pass is, and has decided to make passing this law a test of personal loyalty to him.
That’s a ridiculous way to think about legislation in general. But it’s a particularly egregious way to think about this particular bill, since candidate Trump would have thoroughly denounced it. He promised — in the primary, in the general election, and even during the transition — to put forward a plan that covers everyone, lowers deductibles, and protects Medicaid. He then hashed out a bill that doesn’t do any of those things, and is now professing to be not just eager to pass a bill that defies all of his campaign commitments but furious at people who are skeptical of the merits. Meanwhile, even if it does pass, the bill would have to be substantially revised to have any chance in the Senate.
There’s simply no reason to be doing this. At best, House members will be taking a politically tough vote for an unpopular bill that doesn’t become law. At worst, it will somehow actually become law, and members will find themselves accountable for the catastrophic consequences they haven’t even bothered to try to understand. All out of misguided loyalty to a president who never supported these ideas and doesn’t appear to have any interest in the content of the legislation.