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The Republican health plan is a huge betrayal of Trump’s campaign promises

And Trump’s voters will pay the highest price.

Donald Trump’s embrace of the American Health Care Act, authored by Paul Ryan and other House Republicans seemingly in collaboration with establishment-minded members of his administration, represents a massive betrayal of his own clear and repeated promises to the American people.

To an extent, sophisticated political journalists always knew Trump was likely to break those promises. And his embrace of conventional, conservative House Republicans such as Mick Mulvaney to run the Office of Management and Budget and Tom Price to run the Department of Health and Human Services was a clear indication that he intended to break them. But it would be a mistake to simply gloss over this breach of faith.

Trump’s embrace of more centrist positions on health care and retirement security was a crucial aspect of his campaign, and there was enough campaign-season tension between Trump and the GOP leadership that a voter could be forgiven for assuming Trump meant what he was saying.

He did not. Trump ran and won promising to cover everyone, avoid Medicaid cuts, and boost funding for opioid abuse treatment. He is now lobbying Congress to pass a bill that does none of those things. Instead, millions will lose insurance and Medicaid spending will be sacrificed on the altar of tax cuts for the rich.

It’s not a surprising result, but in many ways it is a shocking one.

Trump made big, clear promises on health care

Donald Trump did not run a wonkish campaign heavily focused on detailed white papers or background briefings with experts. He did, however, make some pretty clear promises on health care policy.

“I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid,” Trump told the conservative Daily Signal way back in May 2015. “Every other Republican is going to cut, and even if they wouldn’t, they don’t know what to do because they don’t know where the money is. I do.”

This was, strikingly, not a general election pivot to the center, but a commitment Trump made as a candidate in the GOP primary.

That fall, his promises got even bigger. "I am going to take care of everybody," he told 60 Minutes. "I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now."

Even after the election, Trump continued to insist that his plan was to offer patients a more generous deal than they were getting from the Affordable Care Act.

In an early January interview with the Washington Post, he said that Trumpcare would feature “insurance for everybody,” in contrast to an ACA that, while bringing the uninsurance rate to a historic low, has still left 25 million people without coverage. The plans, he said, would have “much lower deductibles.” And ability to pay, he said, wouldn’t be an issue. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”

AHCA doesn’t do any of that

The centerpiece of the Trump-endorsed American Health Care Act, by contrast, is a $600 billion tax cut. Families with incomes below $208,500 per year will see their taxes fall by an average of $0 per year, receiving none of that money. But members of the top 0.1 percent of the income distribution — households with an annual income of more than $3.75 million — will see their taxes fall by an average of $165,090 per year.

If you are a multimillionaire and someone in your family gets sick, in other words, AHCA is going to be great for you.

But when you take $600 billion out of the American health care system and funnel it to a small elite group of people, the inevitable result is that everyone else has to get by with less.

Since Republicans are trying to get the bill into the end zone without an official analysis from the Congressional Budget Office, which would project how many people the plan would cover and how much it would cost, it’s hard to know for sure exactly how many people with go with how much less. But Standard & Poor’s thinks 6 million to 10 million people will lose insurance, while Brookings analysts think the number may be 15 million or higher.

The administration’s current strategy is to simply lie about this and say that nobody is going to lose coverage. But that’s absurd. To enact an enormous tax cut under budget reconciliation rules, you need offsetting long-term spending cuts. That’s why the bill shifts $370 billion in Medicaid costs onto state governments, some of which will obviously respond by throwing people off of the program. AHCA also drastically reduces federal subsidies to help people pay for insurance — in 11 high-cost states, the subsidies are cut in half — meaning many people will drop out.

Trump’s supporters deserve to know they’re getting screwed

While cutting financial assistance overall to ensure that most people are worse off, the American Health Care Act also specifically advantages and disadvantages certain groups of people relative to the ACA. In particular, residents of rural areas where the cost of health insurance is inherently higher due to reduced competition will get less help under the AHCA. Older Americans will also face drastically higher premiums due to laxer regulation of insurance companies.

This means that not only will Trump be betraying his promises in general, but, as Nate Cohn writes for the New York Times, he’ll be specifically harming people who voted for him the most.

Jonathan Weisman, a political editor at the Times, breezily asserts that Trump voters “probably wouldn’t care” about this even if they understood it. It’s certainly true that Trump voters might still support Trump all things considered, regardless of his health care plan, since they likely agree with him about guns, immigration, the environment, abortion, and other topics. But Trump probably didn’t run around the country promising people lower deductibles, universal coverage, and no cuts to Medicaid for no reason at all. He said that stuff because it’s popular.

He broke with the Republican establishment on a key issue, soundly beat their candidates in the primary, and then won a general election boosted by considerable outsider credibility but an unusually low level of institutional party support. And now, in his first major legislative act, he’s betraying that promise.