“I want everyone to know I'm 100 percent behind [the American Health Care Act],” President Trump said today. “The press has not been speaking properly about how great this is going to be. I watch, I say, ‘That’s not the bill we’re passing.’
But does Trump really know what’s in the bill he’s passing, or trying to pass?
With the help of Vox’s Jacob Gardenswartz, I collected and read absolutely everything Donald Trump has said publicly about the AHCA. The transcripts cover speeches, rallies, meetings with congressional leaders, interviews with friendly news outlets, and, of course, tweets.
I learned a few things from the exercise. First, Trump has a very limited set of talking points on health care, and he repeats the same words and sentences constantly — his comfort zone on both the issue and the legislation is very narrow.
Second, Trump seems confused about what the GOP bill does. It is possible, of course, that he knows more than he is saying, and has decided to simply say things that aren’t true. But it’s also possible he’s being spun by more ideologically motivated advisers (that’s certainly the narrative pro-Trump outlets like Breitbart are pushing).
Third, Trump has bought into a caricature of Obamacare’s condition that heavily informs his thinking on both the politics and the policy of the AHCA. This could prove more consequential than people realize.
The AHCA does literally none of the things Trump says it does
On March 8, Trump laid out his case for the American Health Care Act. Here’s what he said:
It follows the guidelines I laid out in my congressional address: a plan that will lower costs, expand choices, increase competition, and ensure health care access for all Americans. This will be a plan where you can choose your doctor. This will be a plan where you can choose your plan.
These talking points are familiar enough that it’s easy to let them fade into the background. But it’s worth taking them seriously. This is Trump’s case for the bill he’s backing. Does he know that literally every single one of these points is wrong?
The AHCA doesn’t lower costs. Apples to apples, the Brookings Institution estimates “that premiums would be 13% (~$1,000) higher under the AHCA than under current law, holding plan generosity and the individual market age distribution fixed at their current law levels.” To the extent that the AHCA sees lower premiums, it’s because older people can’t afford care and younger people buy sparer plans. That is no one’s idea of lowering costs.
The rest of the problems flow from there. Most people will have fewer affordable choices under the AHCA because their subsidies will be so much smaller (and many people will have no affordable choice at all, and so will go uninsured). Competition is likely to fall as the marketplaces shrink — fewer consumers wielding smaller tax credits will not prove an attractive market to insurers.
The idea that the AHCA will “ensure health care access for all Americans” is sufficiently absurd that I’m not even going to spend time on it.
But the idea that it will let you choose your doctor and plan is more interesting — it seems entirely possible to me that Trump doesn’t realize the limited choices people complain about in Obamacare are the result of people being unable to afford more generous plans with broader networks, and it seems likely to me that he doesn’t know the AHCA will make that problem worse, or why conservative health reformers think that’s a good thing.
Then on March 10, Trump said this:
You all remember, you can keep your doctor, you can keep your plan. I know, Greg, you’ve never heard that, right? But it was said many, many times, and it turned out to be not true. This is the time we’re going to get it done.
This is either an extremely foolish thing to say or it is the comment of a man who doesn’t realize that the plan he’s backing would, in a stroke, mean millions of people could no longer afford the subsidized insurance they were using, and would react with fury and surprise when they realize they were betrayed.
Night of the living Obamacare
The absolute constant in Trump’s health care rhetoric is the idea that Obamacare is dead no matter what he does.
“Remember, folks,” he said in Nashville, “if we don't do anything, Obamacare is gone. It's not like, oh gee, it's going to be wonderful in three years. It's gone. It's gone. It's gone. Not working. It's gone.”
He went even further at a meeting of the Republican Study Committee:
"I also want people to know that Obamacare is dead. It’s a dead health care plan. It’s not even a health care plan, frankly. And I watched the architect of the plan, yesterday, I watched the old clip where he said the American people are stupid to have voted for it. I watched Bill Clinton saying this is the craziest thing I’ve ever seen. And only because everyone knows it’s on its last dying feet, the fake news is trying to say good things about it, okay. Fake media. And there is no good news about Obamacare. Obamacare is dead. And unless we gave it massive subsidies in a year from now, or six months from now, it’s not even going to be here. So when they say “more people are on the plan,” there’s not even going to be any people on the plan."
If your only trusted source of information on Obamacare were the furthest reaches of the conservative press, this is the impression of the law you would have. But it’s not true.
In December, Standard & Poor’s released a report arguing that the 2017 premium hikes were a "one-time pricing correction," and that insurers were poised "to start reversing" their losses under the program. Similarly, the Congressional Budget Office finds that “the nongroup market would probably be stable in most areas” even if Obamacare were left untouched.
“Most areas” is, of course, an important caveat — there are definitely areas where Obamacare’s marketplaces need more competition, better risk adjustment, or some other method of premium stabilization. It’s a big, complex law, and it requires tweaking in response to changing conditions and more information.
But Trump’s view is much grimmer than that. He thinks “unless we gave it massive subsidies in a year from now, or six months from now, it’s not even going to be here,” and argued that “there’s not even going to be any people on the plan” unless he does something. This is flatly nonsense, but it might be nonsense Trump believes.
The irony, of course, is that the AHCA will destabilize individual insurance markets further, and lead to far greater coverage losses than if Obamacare were left untouched. His point about subsidies is particularly notable, given that the AHCA’s 10 percent premium decreases rely not just on older Americans fleeing the market and younger Americans buying plans with less coverage, but on $80 billion in subsidies from the new Patient and State Stability Fund to keep insurance markets stable.