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The perverse reality of the Republican health care bill

The more help you need, the less you get.

The Congressional Budget Office’s analysis of the GOP’s American Health Care Act is one of the most singularly devastating documents I’ve seen in American politics. For a thorough explanation of the findings, read Sarah Kliff’s explainer. But here is the one-sentence summary: Under the GOP’s bill, the more help you need, the less you get.

The AHCA would increase the uninsured population by about 24 million people — which is more people than live in New York state. But the raw numbers obscure the cruelty of the choices. The policy is particularly bad for the old, the sick, and the poor. It is particularly good for the rich, the young, and the healthy.

Here, in short, is what the AHCA does. The bill guts Medicaid, halves the value of Obamacare’s insurance subsidies, and allows insurers to charge older Americans 500 percent more than they charge young Americans.

Then it takes the subsidies that are left and reworks them to be worth less to the poor and the old, takes the insurers that are left and lets them change their plans to cover fewer medical expenses for the sick, and rewrites the tax code to offer hundreds of billions of dollars in tax cuts to the rich. As Dylan Matthews writes, it is an act of class warfare by the rich against the poor.

The result isn’t just 24 million fewer people with insurance: Of those who remain insured, the pool is tilted toward younger, healthier people who need help less, because many of the older, poorer people who need the most help can no longer afford insurance. As German Lopez notes, a 64-year-old making $26,500 would see his premiums rise by 750 percent. 750 percent! And with that 64-year-old gone, premiums are a little bit lower, because the pool is a little bit younger.

It is within this context that it is worth reading Speaker Paul Ryan’s response to the report.

“CBO report confirms it,” he tweeted. “American Health Care Act will lower premiums & improve access to quality, affordable care.”

Let’s break that down. According to the CBO, the lower premiums Ryan celebrates (which are, mind you, only 10 percent lower after 10 years — and that’s after rising initially) are largely the product of driving older people out of the market and letting insurers offer plans that cover fewer medical expenses and require more out-of-pocket spending. This is not “lower premiums” as most Americans understand the term.

But it is Ryan’s last five words that demand the most attention. He says his bill will “improve access to quality, affordable care.” I am trying, and failing, to find a way to read this statement generously.

Ryan is not arguing with the CBO score here. He is not saying the CBO is wrong and more people will be covered under his bill. He is saying the CBO is right, and its analysis proves his bill will improve access to quality, affordable care.

So he is saying that a bill that throws 24 million people off insurance is a bill that improves access to quality, affordable care. I am schooled enough in health policy rhetoric to know that “improves access” is meant to be some kind of dodge — you can have access to affordable health insurance even if you choose not to buy it — but a bill that makes heath insurance too expensive for millions to afford doesn’t improve access under any definition of the word.

Perhaps this is overthinking it. Perhaps Ryan did not know what his bill will do, and is now stuck defending it because it’s his bill, and he sees no other choice. Perhaps he has become the “This is fine” dog, cheerfully explaining away the fire raging around him, a fire he has set.

But this is not fine. It is not decent, it is not compassionate, and it is not what Republicans promised. It is a betrayal of Donald Trump’s vow to protect Medicaid from cuts and to pass a health care bill that covers everyone with insurance that has lower deductibles and better coverage. It is a betrayal of Ryan’s promise to give Americans more choices — as it is only when you can afford insurance that you truly have the choice of which plan to buy. It is a betrayal of the older, rural voters who put Republicans in office and who will pay the most for heath insurance under this proposal. It is hard to imagine the electoral reckoning that would follow the implementation of this law.

That’s the thing about setting a fire. You’re often the one who gets burned.