After laboring mightily
Essential features of the Republican plan include: rolling back the expansion of Medicaid, under which 10 million people in 31 states have gained health insurance coverage; dropping the mandate requiring most people to have health insurance in favor of tax incentives to buy on the open market; and replacing the ACA’s premium subsidies, which are based on individuals’ income and the cost of health care where they live, with fixed tax credits of $2,000 to $4,000 depending on age.
Analysts appear united in their assessment that the tax credits as proposed would be inadequate. Combined with the Medicaid changes, they say, the result would be millions of people losing coverage entirely and additional millions paying more for less comprehensive coverage. Particularly hard-hit would be low-income older Americans living in rural areas — many of whom presumably voted for Donald Trump in the belief that he would deliver on his promise to replace the ACA with something better and cheaper that would cover more people. As now seems likely, Trump never had a plan and did not have a clue how to go about formulating one. So now he is tweeting in favor of the House version.
Of course, it may be that at bottom, the GOP proposal is not a health care plan at all but a tax bill giving relief to wealthy individuals and big business. It would repeal the taxes on drug makers, insurers, makers of medical devices and high-income households (a key feature of the Obama administration’s effort to address income inequality) that help finance the ACA. The total revenue drained from the Treasury over 10 years is estimated by the congressional Joint Committee on Taxation to be $460 billion. This has warmed the hearts of the U.S. Chamber of Commerce and Americans for Tax Reform, which never met a tax it could abide.
Elsewhere, though, the Republican plan is not getting much love. As of this writing, those opposing it include the American Medical Association, AARP, the American Nurses Association, the American Hospital Association, the Association of American Medical Colleges, the Children’s Hospital Association, the Catholic Health Association of the United States and a major health insurance industry lobbying group. Dr. J. Mario Molina, chief executive of the insurer Molina Healthcare, isn’t a fan, either. “The central issue is the tax credits are not going to be sufficient,” he told The New York Times, predicting that “insurance companies are going to jack up their rates” because they fear being stuck with more high-cost patients as healthier people choose to go without insurance.
No wonder, then, the House’s Republican majority is rushing to pass the bill this week, before the Congressional Budget Office can provide the official score of its likely effect, and send it on to the Senate, where Sen. Mitch McConnell, the majority leader, has promised to move it directly for a floor vote without any of the hearings and other steps that normally accompany consideration of a complex and far-reaching piece of legislation.
However, this piece of legislative sausage is still being made and the weak link may lie within the ranks of rank-and-file Senate Republicans. Some are fearful of the ill effects of the bill on their constituents and, by implication, on their own political futures, while others simply desire a straight-out repeal of the ACA, leaving health care entirely to the free (but not inexpensive) market. Those hard-right conservatives, who also include some members of the House, are at least honest, unlike the majority of their Republican colleagues, who are hoping to scam the public on a fast-track. But who can blame the latter for thinking it will work? Trump is living proof that you can fool most of the people long enough to get elected.