The American Health Care Act

The GOP attempt at replacing Obamacare, a House bill called the American Health Care Act, or AHCA, has been unpopular almost everywhere since its release on March 6th. The Freedom Caucus, a far-right group of conservatives in the House with 29 members and an outsized impact on GOP legislative efforts, has signaled opposition to the bill as not moving far enough right from the Affordable Care Act. Republican Senators Portman, Capito, Gardner & Murkowski have attacked the bill for being too far right, citing concerns about the AHCA’s changes to Obamacare’s Medicaid expansion. For their part, Congressional Democrats are gearing up for a fight,

But the current health care battle is still mostly a war of words, with few facts entering into the conversation on any side of the conflict. Different factions are emphasizing different aspects of the bill–the left talking about the AHCA as a tax cut for the wealthy disguised as a health care bill, the right complaining about how the bill ups the ACA mandate with harsher, delayed penalties for individuals who experience a gap in coverage–and also making different predictions about the plan’s effects on the healthcare market. Health and Human Services Secretary Tom Price, speaking for the administration, says no one will lose coverage under the new bill:

Meanwhile Speaker of the House Paul Ryan acknowledged in a radio interview that the AHCA will cover fewer Americans than the ACA (“You’re never going to win a coverage beauty contest when it’s free market versus government mandates”). Everybody’s waiting for the CBO to score the bill–well, almost everybody.

The CBO, or Congressional Budget Office, is a nonpartisan agency established in 1974 to provide unbiased analysis of pending and existing legislation. In 2010, when the Affordable Care Act was passed, the CBO estimated the bill would save $143 billion over 10 years and reduce the number of uninsured by 32 million. The CBO’s analysis (and earlier ones) gave the health care debate in 2009 and 2010 a firm underpinning in facts, as well as hard metrics by which to judge the act’s ultimate success or failure. Reasonable people could disagree on whether the ACA was the right solution, but they could no longer disagree on what effect the bill would generally have in terms of cost and coverage.

To Republicans proponents of the new, particularly President Trump, a CBO scoring of the new bill will likely put the lie to statements that have been made about its impact. President Trump has repeatedly promised increases in health care coverage, most notably in a 60 Minutes interview with Scott Pelley in September of last year:

Trump: Everybody’s got to be covered. This is an un-Republican thing for me to say because a lot of times they say, “No, no, the lower 25 percent that can’t afford private.” But–

Scott Pelley: Universal health care?

Donald Trump: I am going to take care of everybody. I don’t care if it costs me votes or not.

GOP leaders’ desire to get the AHCA through as much of the legislative process as possible before the CBO score is released is one reason why the bill made it out of the House Ways and Means Committee with zero changes early Thursday morning. Democrats proposed dozens of amendments and used procedural tactics to extend the debate and delay the vote, which went through on party lines after only 18 hours.

Speaker Ryan and Senate Majority Leader Mitch McConnell also hope that an accelerated legislative path for the bill will enable swift passage before rebellious GOP Congresspeople or the American people have had a chance to absorb the facts and weigh in. Ryan has promised to pass the bill through the House by the end of the month, and McConnell has indicated that the Senate will proceed immediately from there:

Both Republican Congressional leaders particularly seek to avoid having the bill still in progress during upcoming recesses in March and April, when Congress returns home to potential pressure from their constituents. That’s a conversation, in town halls and other methods of public interaction with Congresspeople, that the GOP is desperate not to have, particularly since the CBO estimate is likely to be the only significant new data point with regards to this attempt at ACA repeal.

Proceeding with passage of this enormous and complex set of health care reforms before the CBO has had a chance to release their nonpartisan analysis and before the public and legislators have had a chance to react it is troubling for two reasons.

First, it’s simply poor legislative practice for legislators not to know the most crucial details about the impact of the laws on which they’re voting. Things might be different if the AHCA were radically different in form compared to the ACA (although even then it would be poor practice not to have the CBO score it first), but even some conservatives are calling the bill “Obamacare-lite,” as the AHCA’s basic structure of consumer protections (like young people being allowed to stay on their parents’ insurance until they’re 26), subsidies (in the AHCA, based on age instead of income), and penalties (in the AHCA, a 30% surcharge after a gap in coverage, rather than the ACA’s mandate) essentially mimics Obamacare’s “three-legged stool.” Given that, all that remains to the debate is whether or not this new version of the same idea will increase or lower the number of insured Americans and what it will cost.

Second, trying to pass legislation without independent facts about the impact of that legislation is just one more example of the “post-fact” political paradigm that has existed since the beginning of Trump’s 2016 campaign. From lying about inauguration crowds to accusing President Obama of wiretapping him without evidence, to inventing fake terror attacks and attacking the government’s own jobs reports, the Trump administration is at war with facts, choosing to invent its own reality and ignore any inconvenient truths in order to better accomplish its goals. The AHCA legislative process has thus far been a matter of willfully blind governance, and it remains to be seen whether President Trump or Congressional leaders will ever be forced to open their eyes.

Update 7:11pm March 13 2017:

The CBO released its scoring of the American Health Care Act as expected on Monday. The non-partisan agency concluded that the AHCA is expected to save the government $337 billion over the next 10 years, as the legislation cuts revenue (by removing taxes on the wealthy) by $0.9 trillion and cuts expenditures (by gutting Medicaid and slashing subsidies) by $1.2 trillion. The price of this “savings” is that by 2018 the CBO predicts 14 million fewer people will be insured under the AHCA. That number rises to 21 million in 2020 and 26 million in 2024, the report continues, and then presumably after that the number dwindles because “health care” by that date will be redefined as staying as far away as possible from Mad Max.

On the plus side, the CBO does not believe the AHCA will lead to a death spiral in the insurance industry. That’s not to say that the bill is good; just that it won’t literally cause the apocalypse.

That said, the report indicates that the insurance market is about get more chaotic, as premiums are predicted to rise over the next couple years, fall as states become forced to take on the financial burden of subsidies, and move in different directions for different people depending on age, location, and other factors. In other words, the AHCA is going to create winners and losers in the marketplace going forward.

Then there’s this ominous paragraph:

Because of the magnitude of its budgetary effects, this legislation is “major legislation,” as defined in the rules of the House of Representatives. Hence, it triggers the requirement that the cost estimate, to the greatest extent practicable, include the budgetary impact of its macroeconomic effects. However, because of the very short time available to prepare this cost estimate, quantifying and incorporating those macroeconomic effects have not been practicable.

Essentially, the GOP is trying to jam the bill so fast down everyone’s throat that the CBO didn’t have time to figure out how the AHCA would affect the economy. I’m not an expert in economics or legislative policy, and thanks to the GOP’s efforts to push this bill too quickly to a vote, nobody who is an expert will have time to give a definitive answer. But let me tell you my answer to what the economic effect of tens of millions of people staying sick or going into serious medical debt will be: not good.