There are three problems you could have imagined the manager's amendment to the American Health Care Act trying to fix:
- The Congressional Budget Office estimates the AHCA will lead 24 million more Americans to go uninsured, push millions more into the kind of super-high-deductible care Republicans criticized in the Affordable Care Act, and all that will happen while the richest Americans get hundreds of billions of dollars in tax cuts. Voters — including the downscale rural whites who propelled Donald Trump into the presidency — aren't going to like any of that.
- Virtually every health policy analyst from every side of the aisle thinks the AHCA is poorly constructed and will lead to consequences even its drafters didn't intend. Avik Roy argues there are huge implicit tax increases for the poor who get jobs that lift them out of Medicaid's ranks. Bob Laszewski thinks the plan will drive healthy people out of the insurance markets, creating even worse premium increases than we're seeing under Obamacare. Implementing this bill, as drafted, would be a disaster.
- As written, the AHCA is unlikely to pass the House, and so GOP leadership needs to give House conservatives more reasons to vote for the bill, even if those reasons leave the legislation less likely to succeed in the Senate. For this bill to fail in the House would embarrass Speaker Paul Ryan and President Trump.
Of the three problems in the AHCA, the third is by far the least serious — but it's the only one the manager's amendment even attempts to solve. These aren't changes that address the core problems the GOP health care bill will create for voters, insurers, or states; instead, it's legislation that tries to solve some of the problems the bill creates for conservative legislators. It might yet fall short on even that count.
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This is a trap for Republicans. Both the process and the substance of the American Health Care Act have revealed a political party that has lost sight of the fact that the true test of legislation isn't whether it passes, but whether it works.
Republican leaders have moved this bill as fast as possible, with as little information as possible, and with no evident plan for what will happen if the bill actually becomes law and wreaks havoc in people's lives. This is not the health reform package Donald Trump promised his voters, it's not the health reform package conservative policy experts recommended to House Republicans, and it's not the health reform package that polling shows people want.
About the only thing that can be said for the revised bill is this might be the health reform package that can pass the House. And that appears to be the only problem Republicans care to solve right now.
The major changes to the bill, which were first reported Politico and which Vox has now confirmed, are:
- A change in the tax deductibility of medical expenses that the Senate could harness to boost tax credits for older Americans, to the tune of an estimated $85 billion
- More flexibility for states to add work requirements to Medicaid
- More flexibility for states to take their Medicaid funding as a lump-sum block grant rather than a per-person check
- Accelerating the repeal of Obamacare's tax increases by one year
- Restricting people from rolling unused tax credit money into health savings accounts (apparently to ease concerns of anti-abortion groups)
- Changing Medicaid reimbursement procedures in a way that advantages county governments over state governments (for idiosyncratic reasons, Republicans from New York are high on this provision)
- Changing Medicaid reimbursement rates for the elderly and disabled
- States that haven't accepted Obamacare's Medicaid expansion will no longer have the opportunity to do so.
None of these provisions meaningfully change the underlying legislation, nor any of its flaws. These are mostly tweaks meant to win over hardcore conservatives and Congress members from New York.
The locus of effective opposition to the American Health Care Act has been the House Freedom Caucus. Monday night, its leader, Rep. Mark Meadows, sounded a pessimistic note.
"There are some small tweaks that are good tweaks, but there's not substantial changes in the manager's amendment that would make anybody be more compelled to vote for this," he said. "I don't think that the bill will pass without substantial changes."
Meadows may, of course, be wrong. Trump is lobbying individual House Republicans hard, and it's possible a critical number of conservatives will be swayed by Ryan's argument that this is their last, best, and only chance to repeal Obamacare.
But it's also possible that the bill fails in the House. Some conservatives think they can get a better deal by holding strong, even though the better deal they seek would ensure the legislation is dead on arrival in the Senate, if it even makes it to the Senate.
One dynamic that may work against Ryan and the legislation is the secrecy, speed, and unilateralism of the process. The bill hasn't been heavily debated or seriously amended in the committees. The changes to the bill were made by leadership, and they were made fast. Long legislative efforts are annoying for everyone involved, but the reason they're undertaken is that the process leaves members feeling heard, and feeling bought into the end result.
The House GOP leadership has decided that their bill is unlikely to survive a longer and more open drafting process, and so they need to jam it through the House as fast as humanly possible. It took the House more than five months to pass the first iteration of the Affordable Care Act. Republicans are trying to clear their bill in mere weeks. (See this excellent Sarah Kliff piece for more on the stunning hypocrisy at play here.)
I keep thinking about something that New York Times columnist Ross Douthat wrote today. "Republican politicians may offer pandering promises of lower deductibles and co-pays, but the coherent conservative position is that cheaper plans with higher deductibles are a very good thing," he said. It's a gently written sentence, but it's damning beyond measure.
Republicans have been promising the literal opposite of the bill they are trying to pass. Trump swore he'd oppose Medicaid cuts — but this law has more than $800 billion of them. He said everyone would be covered — but the CBO estimates this bill will push up the ranks of the uninsured by 24 million people. Republicans everywhere said they would replace Obamacare with a plan that ensured more competition, lower premiums and deductibles, and an end to skyrocketing annual increases — but this bill will have the opposite effect for most of those affected.
So what happens when voters realize their new tax credit doesn't cover anything close to the insurance they had? What happens when they find themselves with fewer choices, paying much higher premiums after their smaller subsidies, and being told by insurers that costs are doubling because Republicans changed how much more the old could be charged than the young?
Voters will notice all this. And what are Republicans going to say then? That it's all Barack Obama's fault? That high deductibles are actually good, they just forgot to mention it? That they needed something they could pass quickly so they could move on to tax reform?
This bill has always seemed like an answer to the question, "What can we pass that would count as repealing and replacing Obamacare?" But that's not the right question. The right question is, "What can we pass that will actually make people's lives better?" Given the truncated, fearful process Republicans have retreated behind, I'm not persuaded even they believe this bill is the answer.
Commentary by Ezra Klein, editor-in-chief at Vox. Follow him on Twitter @ezraklein.
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