A draft House Republican repeal bill would dismantle the Obamacare subsidies and scrap its Medicaid expansion, according to a copy of the proposal obtained by POLITICO.The legislation would take down the foundation of Obamacare, including the unpopular individual mandate, subsidies based on people's income, and all of the law's taxes. It would significantly roll back Medicaid spending and give states money to create high risk pools for some people with pre-existing conditions. Some elements would be effective right away; others not until 2020.The replacement would be paid for by limiting tax breaks on generous health plans people get at work -- an idea that is similar to the Obamacare "Cadillac tax" that Republicans have fought to repeal.
One of the most important angles to the long-awaited Republican health-care plan is the context: Americans have been promised that the GOP alternative to the Affordable Care Act would meet a series of key benchmarks.As a presidential candidate, Donald Trump promised, "I am going to take care of everybody. I don't care if it costs me votes or not. Everybody's going to be taken care of much better than they're taken care of now." After the election, the Republican president vowed, "We're going to have insurance for everybody.... Everybody's going to be taken care of."And it's against this backdrop that Politico, among others, reported on Friday on the GOP plan that makes no meaningful effort to keep any of Team Trump's promises.
It's worth emphasizing that this refers to an actual bill. Before members took a break last week, House Speaker Paul Ryan (R-Wis.) sent Republican lawmakers home with a series of talking points related to health care policy, including the vague outline of a GOP blueprint, but the draft that emerged late last week is actual legislative text, not a public-relations document.And as is obvious reviewing the bill, it's a doozy. By replacing the ACA with this Republican approach, the wealthy would get a massive tax break, while assistance to working families would be reduced and Medicaid expansion would face a big cut. To pay for their policy, GOP leaders intend to begin taxing employer-provided insurance -- a policy that would cause massive disruptions and which many Republicans have already dismissed as a non-starter.Of course, the question on everyone's mind is the probably the most obvious: how many Americans would lose their health security as a result of the Republican policy? It's an unsatisfying answer, but we're not yet sure.A Huffington Post report explained, "Without a formal analysis from the Congressional Budget Office -- and without careful study by outside experts, most of whom hadn't seen the legislation until Friday -- it's difficult to say exactly how the law might affect premiums, generosity of coverage, the federal budget or the overall number of people with insurance... But the number of uninsured Americans, currently at a historic low thanks to the 2010 law, would almost certainly rise if something like this proposal became law."An analysis presented by the National Governors Association, conducted by the health research firm Avalere Health and the consulting firm McKinsey and Company, told state chief executives that the Republican plan, in its current form, would likely do significant harm to the nation's uninsured rate -- which has dropped to unprecedented lows since the Affordable Care Act was implemented.While we wait for some of these detailed assessments to come together -- unconfirmed rumors suggest the CBO already took a crack at it, and the results were so awful, Republicans buried the findings -- it's important to acknowledge that there's a little something for everyone to hate in this plan. Democrats will scream bloody murder about the fact that this policy directs federal resources away from the poor and towards the rich. Republicans will balk at the new tax scheme that finances the policy.Seniors and their advocates will reject the increased costs for the elderly. Patient advocates will balk at the lack of protections for those with pre-existing conditions. And a variety of stakeholders -- including governors and hospitals -- will take aim at the cruel Medicaid cuts.In case that weren't quite enough, there's also a culture-war component to this: Vox noted that the Republican bill not only defunds Planned Parenthood, but also "threatens to dismantle the entire private insurance market for abortion coverage." [Disclosure: my wife works for Planned Parenthood, but played no role in this piece.]And then, of course, there are the high-risk pools Paul Ryan is so fond of, which have proven "insufficient to meet the needs of sick Americans."It's difficult to imagine a plan like this passing, especially against the backdrop of spirited pro-health-care activism and an unpopular Republican president unable to extend cover to his allies. In a side-by-side comparison with "Obamacare" -- and believe me, those brutal comparisons are on the way -- the vast majority of Americans are going to strongly prefer the ACA to this Republican "solution." The public pushback will be so severe that the only lawmakers who'd vote for this are the ones who are guaranteed to run unopposed.As for the other end of Pennsylvania Avenue, Trump still can't be bothered to brush up on the details of health care policy, but if he intends to have a system in line with his own promises, the president will have no choice but to distance himself from the bill House Republican leaders put together.Postscript: The Wall Street Journal reports this morning that congressional GOP leaders are planning to move forward with their bill, without any real sense of its support among rank-and-file Republicans, effectively daring their members to try to stop it. This never turns out well.