Last night, the House GOP released the text of the American Health Care Act. Essentially the bill cuts taxes, replaces Obamacare’s subsidies with less generous but more far-reaching tax credits (which look a lot like subsidies), kills the individual mandate and replaces it with a requirement to maintain continuous coverage or be subject to a price hike on insurance, kills the Obamacare age band (which forbids insurance companies from charging older enrollees more than three times what they charge younger enrollees), and effectively puts an end-date on Obamacare’s Medicaid expansion.
Republicans have complained that the Obamacare system is too expensive for consumers and that it leaves too many people uncovered. Those are legitimate gripes with the Affordable Care Act (ACA), which has seen premiums increase, which leaves many people able to afford only less generous plans with high deductibles, and which has still left many people uninsured. The problem with the House bill that just came out, though, is that it does nothing to solve those problems. Insurance will get more expensive for many Americans (both as an intended and unintended consequence). Many people will still be left with plans that don’t cover much, and many people will still be left unable to afford insurance. In fact, the bill does not appear to solve any pressing issues with the health insurance market. It will likely make insurance cheaper for some Americans (mainly the young and healthy), but it will almost certainly make insurance more expensive for older, sicker Americans. Its continuous coverage provision incentivizes healthy people who lose their insurance to remain uninsured until they get sick, diluting the pool. Its tax credits are not generous enough to help poorer Americans, and its sunset on the Medicaid expansion will leave many uninsured in the future.
It’s fair to ask: what’s the point? The House bill does not usher in a new framework for health care; instead, it takes the Obamacare framework and makes it less generous. Many on the right are attacking the bill as Obamacare 2.0, not an unfair characterization. The bill does not get rid of anything in Obamacare outright. Instead, it replaces much of it with less open-handed, or less effective, substitutes.
So far, we have not even touched the ways in which this bill falls short of Trump’s promises. He has said, at various times, that the health care will be far better, that it will be cheaper, and that everyone will be covered (a promise he hasn’t repeated since January). This bill fulfills exactly none of those promises. It contains no provisions that would make health insurance better for an average consumer. It does not make deductibles lower or plans more generous. It does nothing to control costs, and at best is neutral on that front. Younger Americans may get cheaper coverage, but older ones will, by design, get more expensive coverage. The tax credits will cover some of the burden, but they will fall short for many, many people, and will be superfluous for more still. Perhaps most importantly, the bill does nothing to expand coverage, and in fact, gets rid of the lever (the mandate) used to propel Obamacare’s expansion in coverage, and replaces it with something that offers little incentive for healthy people to remain insured. The Congressional Budget Office (CBO) has not scored the bill, so we don’t yet have official projections, but early estimates suggest this bill will cover millions fewer than were covered under Obamacare.
Republicans have a tough sell, though they’ve done everything they can to avoid having to really fight for the bill. They want to do this through reconciliation, meaning they will need only a simple majority in the Senate, and so they mainly need to sell fellow Republicans on a bill that appears to be no one’s idea of a fix. The President has never shown any interest in learning the details of health care policy, but is nevertheless behind the bill, and is already warning members of the House of an “electoral bloodbath” in 2018 if they do not get in line. On the one hand, maybe he’s right. Republicans have campaigned for 7 years on Obamacare repeal, and they have the chance to do it now, so they should probably follow through. On the other hand, though, they’re going to try to pass a bill that solves no pressing problems, creates several more, and that causes considerable, real-life pain to a large bloc of voters. They’re doing it while tied to an unpopular President who may well become even less popular in the coming year, and they’re not getting very much of what they want in return. What’s the point?
The GOP has been adamant that Obamacare was a disaster even before the bill was implemented. Their solution is to replace it with something that does even worse on the measures by which Obamacare is supposed to be failing. They may make things better for some (rich Americans who see their taxes cut, younger, healthier Americans who are able to buy cheaper plans), but they will undoubtedly make things worse for many more (poorer Americans, older Americans). And they’re doing it basically for no good reason. The purpose is not to fix Obamacare, because the bill doesn’t do that. The purpose is not to get rid of Obamacare, because the bill doesn’t do that either. The purpose is not to address urgent problems with our health care system as a whole, because it does not do that. The purpose is not to deliver to a majority of the population something it wants, because it doesn’t do that. They are doing this needlessly, shamelessly, and they are not taking the very real problems with our health care system seriously. It looks as if they’re going to succeed, though if there’s any justice left, they should suffer for it.