If it passes, the American Health Care Act will be Donald Trump and Paul Ryan's Iraq War. It's been sold with lies. It's been pushed forward with a shock-and-awe legislative strategy. And its architects are woefully unprepared for the chaos it would unleash upon passage.
There is an honest argument that could have been made for the AHCA. Conservatives believe it is not the government’s responsibility to ensure the poor can afford decent health insurance. They argue that if taxpayers are pitching in for someone’s coverage, that coverage should be lean; a high-deductible plan that protects against catastrophic medical expenses is plenty for charity care. Under this view, the basic structure of Obamacare — which taxes the rich to purchase reasonably generous coverage for the poor — is ill-conceived and should be reversed.
The core philosophical disagreement here is real and worth hashing out. Whereas liberals see access to health care as a right, conservatives see it as more akin to transportation — important, and perhaps worth subsidizing at low levels, but if someone can’t afford a car, it’s not the government’s responsibility to buy them one, much less buy them a nice one. This is the viewpoint the AHCA reflects.
It is not the viewpoint elected Republicans are selling. Instead, their rhetoric fits the sort of plan that Sen. Bernie Sanders might offer. Donald Trump won the 2016 election promising to protect Medicaid from cuts and ensure coverage for all. After the election, he reiterated the vow, telling the Washington Post “we’re going to have insurance for everybody” with “much lower deductibles.”
I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid. Huckabee copied me.— Donald J. Trump (@realDonaldTrump) May 7, 2015
At about the same time, Senate Majority Leader Mitch McConnell went on Face the Nation to lament that under Obamacare, 25 million people remained uninsured, and many of those who did get coverage were in plans where the “deductibles are so high that it’s really not worth much to them.”
Much as Americans were told the Iraq War was about removing the threat of Saddam Hussein’s weapons of mass destruction, they have been told that the GOP’s health care effort is about replacing Obamacare with “something terrific” — a plan that covers everyone with good health insurance that they can actually afford to use. In both cases, they were lied to.
Just as there were no WMDs in Iraq, there is no health insurance Eden where everyone has better coverage at lower costs waiting on the other side of the AHCA — and there will be no hiding that fact if the law passes. The Congressional Budget Office estimates the bill would eventually push 24 million people into the ranks of the uninsured, and it would be particularly punishing to the old and the poor and the sick. The architecture of the bill pushes insurers to create plans with higher deductibles and less coverage and the shrunken tax credits push consumers towards crummier insurance. The experience most people affected by the AHCA will have is either giving up health insurance altogether or trading down into a cheaper plan with much higher out-of-pocket spending.
This is not what Republicans promised — and it explains why they have rushed their bill through Congress so fast. Their legislation does not do what they say it does, and it does not do what voters want it to do, and so a normal, deliberative process that exposed those facts would be lethal.
Shock and awe as a legislative strategy
At a Monday rally, Trump laid out a capsule legislative history of the Affordable Care Act. “It’s important to realize how we got to Obamacare in the first place, back in 2009 and 2010, House and Senate Democrats forced through a 2,700-page health care bill that no one read and no one understood,” he said. “They ignored the public, they ignored the voters, and they jammed a massive failed health care takeover right through Congress.”
A quick review of the Affordable Care Act’s history is in order. In the House, then-Speaker Nancy Pelosi introduced the Democrats’ health care plan on June 19, 2009. The bill wouldn’t pass the chamber until November. It wouldn’t pass the Senate until the end of December. And it wouldn’t pass into law until March of the following year. Over that period, the House and Senate would vote on literally thousands of amendments, and Senate Finance Chair Max Baucus would huddle with two Democrats and three Republicans for months in an effort to work out a bipartisan compromise.
Republicans, by contrast, are attempting to pass their bill through the House less than 20 days after introducing it. They are trying to pass it through the Senate less than 30 days after introducing it. They are doing so without even a token effort to win over Democratic support; they are doing so even though the bill is already unpopular; and they are doing so despite loud, persistent warnings from stakeholders, experts, and even allied think tanks that the bill’s fundamental construction is flawed.
I don’t recount this history merely to mount a charge of hypocrisy — though the hypocrisy on display here is genuinely breathtaking.
Rather, while I didn’t buy the GOP’s argument that the process that led to Obamacare was a secretive, arrogant, undeliberative mess, I thought Republicans did. As Trump’s comments from this very week show, Republicans have spent years arguing, consistently, that Democrats made an awful mistake in 2009 — they moved too fast, ignored public opinion, steamrolled congressional opposition, and ended up with a bad law because of it.
But Republicans have taken everything they said they didn’t like about the process behind Obamacare and supercharged it — it’s as if they’re using their critique of the ACA process as a playbook for retribution. They are moving faster than Democrats did, and they are doing so with less stakeholder support, with a smaller congressional majority, with less bipartisan input, with an unpopular bill backed by an unpopular president, with less information about what their bill would do, and while providing fewer opportunities for members of Congress to amend and improve the underlying ideas.
At this point, the strategy has developed an air of farce. I am publishing this piece on the morning of Thursday, March 23rd, the day the House is supposed to vote on its legislation reshaping the American health care system — and no one even knows what the final bill will look like, as House leadership is in last-minute negotiations with the conservative Freedom Caucus.
But the vote is still expected this evening, even though that will mean there’s no time for congressional or outside analysts to model the altered legislation. Republicans know not what they do, and more crazily, they like it that way — the absence of information has been seen, from the start, as a feature, not a bug.
It's 6am and not one person in America knows what the hell the house is even going to vote on today.— Christopher Hayes (@chrislhayes) March 23, 2017
Republicans are lashing themselves to this insane process because they think it’s their only chance. Either they move fast or their effort perishes. “The Republican leadership has made a decision that time is of the essence here,” says Lanhee Chen, a Hoover Institute fellow who served as policy director to Mitt Romney. “Now, would it be great to have all the information we need in place while or before we have these discussions? In an ideal world, yes. But I also think that runs up against the reality that the deeper we go into this process, the harder it will be to achieve certain policy and political goals.”
This is the cost of constructing a plan that people will like less as they understand it more: You have to make up in political momentum and legislative speed what you don’t have in popular support and defensible policy. But the problems Republicans are trying to obscure through congressional strategy actually need to be solved if the bill is going to work — and that, Republicans need to remember, is the real point of all this.
The 2003 “shock and awe” campaign to topple Saddam Hussein reflected a misconception that the hard part of the Iraq War would be fighting through to Baghdad — but once we were there, and once Hussein was gone, it would all work out. It didn’t. The hard part was after Hussein fell, and the United States was responsible for the future of a country it didn’t understand and faced with chaos it hadn’t planned for.
President George W. Bush famously called the invasion of Iraq a “catastrophic success” — it was a military victory that left America embroiled in a catastrophe. Of course the misery caused by the invasion of Iraq — hundreds of thousands dead, impoverished, brutalized, for no reason at all — is different both in degree and kind than the misery caused by the ACHA would be.
But here, again, Republicans have misunderstood the challenge before them. This bill has always seemed like an answer to the question, “What can we pass that would count as repealing and replacing Obamacare?” But that’s not the right question. The right question is, “What can we pass that will actually make people’s lives better?” Given the truncated, fearful process Republicans have retreated behind, I’m not persuaded even they believe this bill is the answer.
With a sufficient congressional majority, and sufficient arm twisting, Republicans can pass a bill. The problem is what happens once Obamacare is toppled and they need to rebuild the health care system they’ve destroyed, manage the fury of the voters they’ve betrayed, and explain away the insurance markets and rural health care systems they’ve wrecked.
You break it, you buy it
In the runup to the Iraq War, Secretary of State Colin Powell famously told President Bush, "You are going to be the proud owner of 25 million people. You will own all their hopes, aspirations, and problems. You'll own it all." Privately, he referred to this as the Pottery Barn rule: You break it, you own it. (For the record, it turns out Pottery Barn does not actually have this rule.)
This is a problem that afflicted Democrats too. After passing Obamacare, they found themselves responsible for both the law’s problems and the broader, systemwide problems that had nothing to do with the law. If employers raised premiums — which they did before the Affordable Care Act, too — Obamacare got blamed. If local hospitals closed, Obamacare got blamed. And all this happened even as they pumped new money into the system, insuring tens of millions of people.
If Republicans pass the American Health Care Act, they will be blamed, correctly, for tens of millions of people losing their health insurance and for untold others who have to trade down to plans with higher deductibles and more cost sharing — exactly what Trump promised wouldn’t happen.
But they’ll also be blamed for the sundry chaos their plan creates: the local insurance markets that collapse because all the insurers pull out, the seniors who find their premiums quadrupling, the rural health systems that crack under the thinner subsidies, the low-income workers whose raises push them above Medicaid eligibility only to find their larger paychecks more than consumed by larger health bills.
Some of these problems are not what Republicans intend — they’ll be the result of a poorly constructed bill the GOP hasn’t taken the time to consider and fix. But this is a choice they’re making in moving so fast: The schedule they’ve adopted doesn’t give them nearly enough time to understand what the American Health Care Act will break.
To all this, Republicans have an answer: Just wait for phases two and three of health reform! In the GOP’s telling, everything that is not in this bill will be added in phase two, when Health and Human Service Secretary Tom Price reinterprets unspecified regulations to strengthen insurance markets, and in phase three, when Republicans attain a 60-vote Senate majority and pass all the changes they couldn’t fit through the filibuster-proof budget reconciliation process.
Don't worry, getting rid of state lines, which will promote competition, will be in phase 2 & 3 of healthcare rollout. @foxandfriends— Donald J. Trump (@realDonaldTrump) March 7, 2017
The very absurdity of this plan shows the depths of the GOP’s self-delusion. This is the heath care version of Dick Cheney’s promise that American troops “will, in fact, be greeted as liberators.” When that didn’t happen, the inadequacy of America’s postwar planning was laid bare, and a catastrophe unfolded. Here, too, Republicans are building their health plan around a blindly optimistic post-passage scenario, and when it fails to come true, they will own a catastrophe.
Republicans are creating a policy vacuum they may not be the ones to fill
Here, I think, is a plausible vision for what might follow passage of the American Health Care Act. In 2018 — the AHCA’s first real year of operation — the ranks of the uninsured will rise by 14 million, as the Congressional Budget Office has predicted. Not all those people will be losing health insurance they already had, but most will. Millions more will find their tax credits insufficient to cover the plan they had, and liked, and will be left paying more out of pocket for insurance that covers less. The news will be thick with stories of counties where insurers jack up premiums to manage the market upheaval, and there will likely be some areas that find themselves with no insurers offering coverage at all.
Those reports will be the easier ones for Republicans to ignore. Though it is uncomfortable to speak in these terms, people will die if they can no longer afford health insurance. A cautious estimate, based off the best available evidence, suggests coverage losses on the scale Republicans envision will lead to more than 24,000 deaths annually. This is a major difference from Obamacare, which also caused disruptions in the health insurance market, but did so while covering millions of people and saving lives. The AHCA, in taking coverage from millions, will generate wrenching stories of human suffering — stories that power ads and protests and campaigns all across the country.
Next will come the midterm elections — and Democrats will ride the fury of their side, Trump’s unpopularity, and anger over health care to massive gains in the House. Then in 2020, the Medicaid expansion will freeze, and restoring both it and Obamacare’s broader coverage gains will be the animating issue for Democrats. The Republican zeal to repeal Obamacare will be matched by the Democratic zeal to restore and expand it — and Democrats, unlike Republicans, will actually have a plan that accords with their rhetoric.
If a Democrat wins the presidential election — and whether it happens in 2020 or it happens later, the party will win power back eventually — Democrats won’t waste time mucking about with the lengthy, bipartisan process and centrist ideas that animated the Affordable Care Act. They will not scour the country for a health plan implemented by a Republican governor, as Obama did before finding Mitt Romney’s reforms in Massachusetts. They will have learned that no Republican aid is forthcoming, and that there is no point in attempting to find it. Republicans have, at this point, firmly discredited Democratic moderates and their promises of technocratic compromises.
Instead, Democrats could, within a matter of weeks, pass a short, clear law restoring and expanding the Medicaid expansion, restoring and expanding Obamacare’s tax credits, allowing Americans to buy into Medicare as an option on the exchanges, and paying for the whole thing by levying hefty taxes on the rich. The bill would be easy to write and easier to explain.
In this, Democrats would be passing exactly what Republicans have promised: lower-deductible care that everyone can access. This is the core advantage Democrats have in this fight: Their basic agenda of taxing the rich to offer generous health insurance to the poor is popular enough that they can sell their legislation based on what it actually does. To the extent that Obamacare is unpopular, it is unpopular because it strayed too far from that theory — it tried to hold down tax increases down by cutting Medicare, and tried to hold down total costs at the expense of keeping premiums and deductibles low for the middle class. Those were choices Democrats made to attract moderate Republicans and centrist Democrats in a process that required 60 votes to pass anything. They will not make those choices again.
This is only one possible scenario, of course. You can come up with your own. The broader point is that toppling a regime without a stable or popular plan for the aftermath rarely goes well. If Republicans upend Obamacare, their replacement plan is unlikely to survive the aftermath — it’s simply too different from what voters want, too vulnerable to future change, too loathed by existing interest groups, and too shoddily constructed to build support on its own merits. Rather, their plan will create chaos in insurance markets, anger among voters, and radicalization among their opponents; the policy that eventually fills the vacuum they create will not be one they like.