The American Health Care Act, passed today by the US House of Representatives, is a law that fundamentally does the reverse of what its proponents are promising.
Having run a campaign during which he promised to cover everyone, protect Medicaid from cuts, and replace Affordable Care Act plans with “terrific” coverage, Donald Trump is now behind a bill that cuts Medicaid, covers fewer people, and allows states to replace ACA plans with stingier coverage. Having promised repeatedly to protect patients with preexisting health conditions from insurance market price discrimination, Paul Ryan is pushing a plan that removes existing protections and replaces them with hand-wavy and inadequately funded high-risk pools. Having leveraged public discontent with high deductibles and rising premiums, Republicans are pushing a bill that will leave most patients with higher out-of-pocket costs for equivalent plans and bring back skimpy plans with even higher deductibles.
That’s all happening because the GOP is committed to rolling back the taxes that pay for the Affordable Care Act, delivering a financial windfall to high-income families even though Treasury Secretary Steve Mnuchin swore at his confirmation hearings that the Trump administration would not pursue tax cuts for the rich.
The bill is currently being rushed through the House at breathtaking speed with no time for a Congressional Budget Office score or for members to hear from constituents back home. Republicans are acting like their plan cannot survive even cursory scrutiny by experts or the public for the good reason that their own rhetoric strongly suggests that they do not believe the public would find this legislation acceptable if they knew what it did.
The new AHCA breaks the GOP’s promises on preexisting conditions
When Ryan initially rolled out the American Health Care Act, he accompanied it with a Frequently Asked Questions page that offered a firm statement of moral purpose regarding the treatment of patients with preexisting conditions:
That statement is now gone from the House leadership’s website. In search of additional Freedom Caucus votes, Ryan abandoned that commitment and signed on to the MacArthur Amendment that will, in fact, allow insurers to charge higher premiums to sick people.
In its place is a new claim that the legislation is okay because it includes an amendment from Fred Upton that Ryan says “strengthens the AHCA by reaffirming our commitment to protect patients with preexisting conditions.”
It does not, in fact, do that. What it does is provide $8 billion in extra money that states could try to use over five years to partially defray the massive increases in costs that patients with preexisting conditions will face under MacArthur’s plans. But it’s not nearly enough money. As Larry Leavitt of the Kaiser Family Foundation tells Vox’s Dylan Scott, AHCA waivers could lead to “massive premium increases” and “there’s no way a reinsurance program or direct subsidies could ever fully offset that for everyone, and states aren't required to do so.”
Trump ran on big health care promises
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.”
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
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 breaks all of Trump’s commitments
The reality of AHCA is close to the reverse of what Trump promised:
- It enacts drastic cuts to Medicaid, amounting to $370 billion over 10 years.
- AHCA will lead to higher premiums in many cases, especially for people with the largest objective financial or health care needs, in which case premiums could rise by as much as 750 percent.
- Far from covering everybody, the original version of AHCA is forecast to increase the ranks of the uninsured by as much as 24 million. Nobody is quite sure how much the deregulatory provisions added this week will alter that because House Republicans haven’t bothered to take the time to get a new score of the bill.
- Deductibles are forecast to rise by about $1,500 on average.
And while most other Republican leaders were a little less sloppy in their lying about their health care agenda, Trump is far from the only one who’s been misleading the public about the basic direction of their push. On the January 8 edition of Face The Nation, Senate Majority Leader Mitch McConnell listed the Affordable Care Act’s failings: “If the idea behind Obamacare was to get everyone covered, that’s one of the many failures. In addition to premiums going up, copayments going up, deductibles going up.”
The bill his party is now pushing will cover fewer people, charge higher premiums, raise copayments, and raise deductibles.
The reason is that the AHCA takes a ton of money out of the health care system in order to provide a $600 billion tax cut, overwhelmingly for the richest households. That, too, is a broken promise that violates Treasury Secretary Steve Mnuchin’s confirmation hearing promise that the Trump administration would pursue “no absolute tax cut for the upper class” in its policy agenda.
Reality bites — or not
AHCA’s initial collapse in March seemed, at first blush, to be largely driven by the weight of these lies and contradictions. It is relatively easy to confuse people with misleading political rhetoric, especially if ideologically friendly media outlets are prepared to play along with you.
It’s harder to confuse people about reality. While running for president, for example, Barack Obama promised that his health plan would lead to lower premiums for average families. When pressed, his policy team would gladly clarify that what he meant was premiums would increase at a lower-than-expected rate. That was a reasonable promise, but not nearly so politically appealing as the much grander promise the candidate made in his speeches. And the policy of misleading people worked well enough until he was actually in office, signed a major health care bill, and then people discovered that their premiums were not, in fact, going down.
AHCA, if it becomes law, will put that dynamic on steroids. There’s going to be no way to trick people into believing their insurance plans are getting cheaper and better if they are in fact getting worse, or to dupe people who’ve just lost coverage into believing they haven’t. Patients with preexisting conditions will see with their own eyes that no commitments have been strengthened.
This all made Republican members of Congress nervous about voting for a bill whose political viability appeared to hinge entirely on it never actually passing so that nobody ever found out what was in it. Over the past month, however, the calculus seems to have changed.
Failure to pass an Obamacare repeal plan was creating a logjam for the rest of the Republican legislative agenda, and nobody wanted to be responsible for holding up the works. Health care became a legislative hot potato that House Republicans are now determined to pass to the Senate as soon as possible, completely ignoring the fact that the bill does the opposite of what they are promising.
It’s a bill that’s sold on a giant pack of lies, without thorough vetting.