The president and his GOP allies on Capitol Hill already have rammed through two U.S. House committees a plan to repeal and replace the Affordable Care Act, aka Obamacare. But to paraphrase a best-seller’s title, those who will be affected by the American Health Care Act, the AHCA, are from Earth, while the Republicans who are pushing Trumpcare must be from Pluto.
That’s because their Trumpcare, as evidence already has shown, will divide Americans as never before, while at the same time unifying them in opposition to it and disbelief about its current form.
Here’s what the suddenly engaged, now arm-twisting president Tweeted about the House legislation: “Our wonderful new Healthcare Bill is now out for review and negotiation. ObamaCare is a complete and total disaster— is imploding fast!”
But here’s what Avik Roy, a leading conservative writer on health policy, said of Trumpcare and its likely fiscal assessment by the Congressional Budget Office: “ The CBO is likely to score the AHCA as covering around 20 million fewer Americans than Obamacare. There are flaws in the way the CBO models health reform legislation, but the AHCA itself contains enough flaws that there can be little doubt that the plan will price millions out of the health insurance market. Expanding subsidies for high earners, and cutting health coverage off from the working poor: it sounds like a left-wing caricature of mustache-twirling, top-hatted Republican fat cats. But not today.”
Here’s what House Speaker Paul Ryan insists about the Trumpcare draft he’s pushing: “It repeals Obamacare’s taxes; it repeals Obamacare’s spending; it repeals Obamacare’s mandates. It creates a vibrant market where insurance companies compete for your business. Where you have lower costs, more choices, and greater control over your healthcare. And it returns power—this is most important—this returns power from Washington back to doctors and patients, back to states. This is what good, conservative healthcare reform looks like.”
But here’s what GOP Sen. Rand Paul of Kentucky, said of the measure: “It won’t work.”
For those not already overwhelmed by the tsunami of Trump and health care coverage, here are some resources to get well informed on the latest saga of Americans and their health insurance:
- For breakdowns of the measure, consider the analytical materials from the independent, nonpartisan Henry J. Kaiser Family Foundation (click here) or the main story and infographics package from the New York Times (click here and here), or the Washington Post report with videos (click here) or there’s an explanatory piece from the online news site Vox (click here),
- To get a sense of how divisive Trumpcare has become, Vox has a useful—and long—chart of detractors. They include major medical groups like the American Medical Association, American Hospital Association, American College of Physicians, and American Nurses Association. America’s Health Insurance Plans, one of the industry’s largest groups, has opposed the Trump-Ryan plan, as has the AARP, the nation’s largest advocacy group for Americans older than 50. Republican Conservatives are up in arms over the AHCA, decrying it, among other things as Obamacare Lite, and assailing it for failing to get the government out of the health care sector. An editor for a prominent publication favoring the GOP right had a comic social media exchange, started when he Tweeted that he had asked his myriad colleagues for any favorable Trumpcare comments. All he had heard was, “crickets,” he said. He then was chastised by an oblivious critic, who told him he needed to expand his circle’s diversity to hear more conservative views. “I’m an editor for the National Review,” he fired back.
Here are some other key takeaways from this complex issue, distilled in a pair of bills that partisans kept secret, sprung on even their own, and for which they have crashed through reviews in just days after lambasting opponents for doing so over a year.
- We still have no official clue about is how much Trumpcare truly gouges Americans, though solid, early indications are that it will toss as many as 15 million off desperately needed health insurance, with millions more likely affected by so-called reforms of the Medicaid program. (I’m tackling the GOP Medicaid assault separately).
- Partisans, with shameful abandon of fiscal responsibility, have advanced the AHCA without any solid knowledge as to what it will cost. They counterfactually are assailing in advance the CBO, the congressional agency that “scores” impacts of important laws from Congress. The GOP haste hasn’t permitted the CBO yet to review Trumpcare.
- Meantime, it’s clear that Trumpcare offers a feeding frenzy for Big Pharma, medical device makers, Big Insurance, tanning salon operators, and, yes, the wealthy by repealing taxes that Obamacare imposed to expand health insurance coverage and to try to make it affordable for more Americans. Partisans haven’t tried to explain how they will replace their giveaway to the rich and powerful, a tab that may run at least $600 billion. Just to underscore the size and scope of the GOP largesse: the top .1 percent of earners each will get a tax cut of almost $200,000 under Trumpcare.
- To be sure, proponents say they are keeping Obamacare aspects embraced by Americans. Insurers still can’t impose lifetime or annual limits on payments to insured. They’re still barred from denying coverage due to pre-existing conditions. They must allow parents to keep on their plans their offspring up to age 26. And, at least for now, Trumpcare keeps minimum benefits, including preventive care. But it repeals the individual mandate, requiring all Americans to carry health insurance or to pay penalities—a step designed to make as large as possible the risk pool, with young and old, sick and healthy.
- Trumpcare changes Obamacare coverage subsidies, moving away from need and to a mostly age based system of tax credits with some income cut-offs. The young will get less than the old, with those in their 20s getting credits of about $2,500 annually versus $4,000 for those 60 or older. Tax credits likely will go further in covering insurance costs for younger Americans, possibly encouraging more to sign up. They still may not do so, because there’s no penalty if they don’t.
- Trumpcare also changes how insurers can use age in charging customers, allowing them to be charged five instead of three or so times what younger customers pay. AARP says this will result in premium hikes of as much as 30 percent for older Americans, making health insurance unaffordable. AARP also says Obamacare boosted Medicare through a tax on high-income workers and by reducing medical costs that depleted the program—benefits not sustained in the AHCA. Meantime, the mere idea of tax credits infuriates Conservative Republicans. They see little difference in these from Obamacare subsidies they despise as government meddling in free markets. Speaker Ryan and Tom Price, Health and Human Services Department secretary and a Trumpcare architect, had to make last-minute changes in Trumpcare tax credits. Without including some income limits, a multi-billionaire like Bill Gates could have received the same tax credit as a pensioner in the District of Columbia scraping by on Social Security. Critics also noted that without the income standards, companies may have been tempted to stop offering health coverage for millions.
- The GOP plan, in place of the individual mandate, penalizes Americans who do not maintain consistent coverage with a 30 percent surcharge on their annual premium. Skeptics don’t think this surcharge will be sufficient to discourage healthy people from skipping insurance, then signing up and paying a penalty when they are sick but can’t be turned away due to preexisting conditions. If this practice proliferates, insurers will be covering many more sick people with big and suddenly covered costs. Experts say this can cause a “death spiral.” The consistent coverage requirement also upsets realists, who note that with job changes, illness, moves, and other human factors, it can be all too easy to let health insurance lapse.
- For women, Trumpcare is bad news. It seeks to defund Planned Parenthood, criticized by Republicans not for the many medical services it offers to women but because some of its facilities, using non-federal funds, allow abortions. Trumpcare also slashes at requirements for insurers to address women’s reproductive and maternal health needs. Californians, who are part of one of the nation’s largest and most successful roll-outs of Obamacare, are starting to wake up to a bad twist in Trumpcare: It bars tax credits paying for any health insurance plan that also covers abortion. California law requires this. So will millions of Golden State residents be barred from Trumpcare benefits because they can’t buy in their state abortion-free policies?
So, for all the tumult that Republicans will put the American people through to repeal and replace Obamacare, what’s Trumpcare’s benefit? Does it improve health care? Does it increase the number of Americans covered? Does it help the poor, sick, and most needy? Does it lower costs, improve safety and efficiencies, and encourage innovation, including with technology, in a sector of the economy that comprises 17.5 percent of GDP? Is it, as the president likes to say, more “beautiful.” Far from it.
Trumpcare, as acrimonious House hearings have illustrated, lacks a constituency—other than ideologues seeking to show their faithful that their hated Obamacare, emphasis on Obama not so much care, will be vanquished. Sort of. But building data underscore that the AHCA savages most the voters who put a Republican Congress in control and a GOP president in the White House. Older, sicker, poorer whites living in rural areas are in for a rude shock under Trumpcare. But so might we all be.
The measure still must go through steps in the House, including more committee reviews and a floor vote. It then goes to the slower, more deliberative Senate, where it will not be subject to committee review but faces a much more uphill battle with skeptical lawmakers and with complex procedural issues. These have been caused by Republicans’ insistence in seeking to repeal Obamacare using the budget reconciliation approach, meaning any changes to the law must be shown to be fiscally related. This has forced partisans at times into such convoluted measures —including a peculiar bill-writing obsession with lottery winners’ eligibility for health care tax credits—that wags have taken to describing their work as “trying to push a giraffe through a keyhole.”
It’s also important to note that, faced with stiff opposition, GOP leaders have taken to emphasizing that their assault on Obamacare will occur in phases—meaning we all have even more awful stuff to see from partisans. Our health and well-being is at stake. We need to keep on top of Trumpcare and to exercise our democratic rights to express to our lawmakers just how aghast we are at this intergalactic mess.