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The Senate GOP’s health care bill is a strange document. It doesn’t fix what conservatives dislike most about Obamacare. But it takes what everyone else hates about Obamacare and makes it much, much worse.
The plan keeps Obamacare’s basic structure intact. The tax credits remain tied to income. Many of the insurance regulations remain in place. Medicaid is, in theory, gutted down the road, but the cuts don’t even begin until 2021 — raising the fear for conservatives that they’ll never happen at all. Even the cost-sharing reductions to insurers — which Republicans bemoaned as an illegal “bailout” — are restored.
So Obamacare — the government program that makes it the state’s responsibility to cover people with health insurance — mostly survives. If you are a conservative angry that the federal government has created a new health care entitlement, this bill doesn’t solve your problem.
But under the Senate bill, Obamacare’s ability to actually cover people with health insurance is sharply diminished. Because the plan shifts hundreds of billions of dollars in insurance subsidies to tax cuts for the wealthy, there’s not enough money in it to cover nearly as many people, with nearly as good insurance, as there is now.
So Obamacare — the program that got more than 20 million people onto (usually) decent health insurance — is gutted. If you are a liberal who supports the Affordable Care Act because it improves people’s lives, this bill will infuriate you.
The new world created by the Senate health care bill will be based around higher-deductible plans that cover fewer health benefits and cost people more. The plan degrades Obamacare’s insurance regulations, and cuts insurance subsidies so that Americans won’t be able to afford plans as generous as the ones they purchase now. If the Medicaid expansion really does die out in 2024, then the poorest of the poor will be pushed from comprehensive, low-cost health insurance to extremely high-deductible plans.
So if you, like most Americans, think Obamacare does some good, but it doesn’t cover enough people, and the people it does cover are paying too much to get too little, you are going to hate this bill.
Who, then, is this bill actually supposed to make happy? Well, if all you really cared about was cutting taxes for rich people and creating the tantalizing prospect of taking Medicaid away from poor people down the road, this bill is for you.
If you thought Obamacare more or less made sense, but the problem was the insurance it offered was too affordable and too good, then this bill definitely works for you.
If you’re Mitch McConnell, and you were looking for something, anything, that could either pass quickly or be killed quickly, this bill might be for you.
But if you’re like most people and you just want to see the health care system made better — if you want people to be able to afford insurance that protects them and their families — this bill is a disaster. Its theory of insurance is there should be less insurance coverage. Its theory of insurance design is insurance should cover fewer medical expenses and carry higher deductibles. Its theory of cost control doesn’t exist. Its theory of stabilizing insurance markets is to shovel subsidies directly to insurers as a payoff for participating. Its theory of the system overall is that we spend too much money on health insurance for poor people and too little money on tax cuts for rich people.
This is a bill designed to solve a political problem Republicans have: They need to do something they can call “repeal and replace” of Obamacare. But its passage would create a much bigger political problem for them: They will own an unstable health care system that people hate.
Wouldn’t it be easier just to cut taxes?
