As House Republicans hurtle toward a vote on a complicated, unpopular piece of health care legislation that has not yet received a proper analysis from the Congressional Budget Office, they face two basic problems.
On the one hand, the American Health Care Act might simply die in the Senate. In that case, vulnerable members will have taken a tough vote on an unpopular bill for no real reason.
On the other hand, the AHCA might actually become law. In that case, all the various gymnastics and talking points and deceptions that surround GOP health care rhetoric will be irrelevant.
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If the bill passes, Americans who were promised better insurance for more people will find that we have worse insurance for fewer people. Americans who were told that people with preexisting health conditions would still be able to find affordable coverage will find that they in fact cannot. Republicans will have set themselves up to reap the whirlwind.
All in all, it's extremely hard to tell what outcome exactly House Republicans are hoping for. Some are offering assurances that since the bill will have to be changed to pass the Senate anyway, there's no reason to sweat the details too much. Others are telling journalists that the latest waiver provisions added to appease the hardliners in the House Freedom Caucus aren't a big deal because no state would be crazy enough to actually ask for them. But mostly, nobody is thinking that far ahead.
Millions of people will lose Medicaid coverage. The health insurance industry will face laxer regulation and be able to offer skimpier plans. Spending on subsidies will fall, so patients will face higher out-of-pocket costs. And in turn, Republicans will be able to roll back Obamacare's tax increases.
The prevailing dynamic is that health care has become a political hot potato and House Republicans are eager to get it out of their hands and over to the Senate. Beyond that, they don't seem to care. And in the mad dash to legislate, the interests of millions of vulnerable Americans are being left behind.
Republicans have painted themselves into a corner
Republicans' basic problem on health care is simple: They want to substantially reduce the amount of money the federal government spends on providing people with health care so they can free up cash for a tax cut on the rich — but cutting taxes on the rich is unpopular, and providing people with health insurance is popular. Consequently, the GOP has chosen to spend years running against the Affordable Care Act on the false premise that Republicans want to replace it with higher-quality health plans.
"We're going to have insurance for everybody," Donald Trump told the Washington Postafter the election. Under Trumpcare, according to Trump, people "can expect to have great health care. It will be in much simplified form. Much less expensive and much better."
This was bolder and brasher than what more establishment-minded Republicans had said over the years. But it was, fundamentally, similar to promises and insinuations made by Paul Ryan, Mitch McConnell, and dozens of other Republicans. It's not just that the Affordable Care Act was killing jobs and sentencing people to death panels. It's that Republicans had some much better plan in their back pocket that would give Americans what they want — cheap, comprehensive health insurance that offers them oodles of choice.
"If the idea behind Obamacare was to get everyone covered," said McConnell on the January 8 episode of Face the Nation, "that's one of the many failures. In addition to premiums going up, copayments going up, deductibles going up."
In other words, the Affordable Care Act had two big problems: Not enough people were covered by exchange plans, and the coverage they had was too skimpy.
"Many Americans who actually did get insurance when they did not have it before have really bad insurance," McConnell continued, sounding like one of the ACA's left-wing critics, "and the deductibles are so high that it's really not worth much to them."
In reality, everything in the various versions of the AHCA points in the opposition direction. Millions of people will lose Medicaid coverage. The health insurance industry will face laxer regulation and be able to offer skimpier plans. Spending on subsidies will fall, so patients will face higher out-of-pocket costs. And in turn, Republicans will be able to roll back Obamacare's tax increases.
The bill has changed through fig leafs, not improvements
In a big-picture sense, that's why the original AHCA failed.
And nothing that's changed since then addresses the basic dissonance. Instead, House leadership has run around chasing votes through a series of epicycles that avoid the core point:
- They got the Freedom Caucus on board by adding provisions that would gut Affordable Care Act consumer protections, thus making the bill even more of an unpopular deregulation machine.
- Then they assuaged nervous vulnerable members by changing that into a provision that would allow state governments to waive the consumer protections, thus allowing moderates to tell themselves that patients were still taken care of.
- When that wasn't good enough, they offered Rep. Fred Upton (R-MI) an $8 billion boost in funding for high-risk pools to take care of people with preexisting conditions. Nobody thinks that's remotely enough money to actually solve the problem, but it allows Upton to say he got changes made to the bill to address the problem.
This is the point at which normal legislators acting in good faith would stop and wait for a new CBO analysis of the bill.
Such an analysis could help us understand what premiums would look like in waiver versus non-waiver states and what kind of plans would be available in the waiver states. It would also help us to understand what the high-risk pools might look like in practice in terms of how many people they could cover.
But Republicans are planning to skip all that, because on a couple of fundamental levels, the caucus has decided it basically doesn't care what the bill actually does. They want to pass the buck to the Senate, and they want to give wavering members the fig leaves that they need to vote "yes." If the goal of your bill is to solve a problem, a CBO score helps you understand how well your efforts are working.
But if the goal is to hand out fig leaves, a rigorous score is probably counterproductive. Analysts at the Committee for a Responsible Federal Budget, for example, think the rewritten bill might accidentally increase the deficit. That's the kind of thing rank-and-file members need to not know if House leadership is going to achieve its core deal of passing a bill as soon as possible.
Doom around the corner
There are basically two kinds of bills that you see in Congress.
Many are "message bills" — pieces of legislation that are intended to signal something, or nothing, but are introduced with the knowledge that they are not actually going to become law. All the various Affordable Care Act repeal bills that House Republicans passed during Barack Obama's presidency were on that model.
Bills that are meant as potential laws are another kettle of fish entirely. The important thing about a message bill is that it needs to sound good, so that if a member of the voting public hears about it, you'll have something to say. With a real law, what you want is consequences that will be good, so that you can stand up and say you played a role in making a good thing happen.
The AHCA as written fails both of those tests.
As a message bill, it doesn't work because it's hideously unpopular. If the House tosses the hot potato to the Senate and it dies there, House members will have voted for a grossly unpopular bill for no particular reason. These things happen — Nancy Pelosi whipped vulnerable Democrats to vote for a cap-and-trade bill that was DOA in the Senate when she was speaker — but normally, prudent politicians try to avoid it.
As a real bill it's even worse, since the legislation simply doesn't do what its proponents are claiming. You can't take hundreds of billions of dollars out of the health care system while also improving the quality of people's health insurance. If the bill passes, people will see that the exact reverse of what they were promised is happening. There's a reason basically every medical advocacy group you can think of opposes this bill.
People will, quite naturally, be mad about it.
That raises the question of not just short-term electoral backlash against the GOP but also what the long-term conservative vision for health policy is supposed to be. Progressives in America have a clear vision — the government should pay for people's health care — that they've been pursuing for decades and will pursue with renewed vigor if the Affordable Care Act effort at a compromise is undone.
Conservative policy wonks have a vision too. But conservative politicians aren't even trying to sell that vision. Instead, they're just lying to people. And if their bill somehow passes, that will be exposed, leaving them with nothing at all.
Commentary by Matt Yglesias, a writer at Vox. Follow him on Twitter @mattyglesias.
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