At the same time, however, the response from certain GOP senators has been far more cautious. Some are saying that they have not read the CBO report and want to reserve judgment. Others are expressing serious worry about the GOP bill’s impact on their states. Louisiana’s Bill Cassidy said that the report’s projection of massive coverage loss is “awful.” Arizona’s John McCain added: “I’m very worried about what the House bill would do to Arizona.”
The disconnect highlights the real significance of the CBO report for the prospects for the GOP health bill — and for our politics in a broader sense. The CBO has laid bare the GOP’s true health-care priorities with a clarity that has long been absent from the political argument over reform, making it harder to conceal them inside a fog of obfuscation and deception.
It probably isn’t an accident that some senators expressing concern about the CBO score come from states that have opted into the Medicaid expansion. One of CBO’s most startling findings concerns Medicaid: the GOP plan would cut Medicaid spending by $880 billion over ten years, resulting in 14 million fewer enrollees. Beginning in 2020, it would scrap Medicaid as an entitlement for those eligible for the expansion, by instituting per-capita limits and a reduction in the cost share picked up by the feds. This would likely result in a greater burden on states, which could lead some states to reduce or restrict benefits, or to opt out of the Medicaid expansion altogether, and thus to a large rollback of assistance to the poorest Americans. This is a big way the GOP bill saves money, enabling it to deliver a massive tax cut to the richest Americans.
This will — or should — put many GOP senators in a very difficult position. If they vote this bill into law, it will mean their states will have to make some very tough choices about their own populations, and many of their own constituents could be harmed. Nearly 20 GOP senators come from states that have expanded Medicaid. (They are: Portman, Toomey, Paul, Flake, McCain, Cotton, Ernst, Capito, Gardner, Murkowski, Heller, Cassidy, Grassley, Hoeven, Daines, Boozman, Sullivan, Kennedy, and McConnell.) It’s telling that some of these have already expressed concerns; now they all will have to decide whether to vote to phase out their state’s Medicaid expansions (among other damaging provisions) while deeply cutting taxes for the rich.
It should be noted that many Republicans support the priorities embedded in the GOP bill for reasons grounded in real principles. Many sincerely believe redistributive policy is morally wrong; that less-regulated markets are the best way to increase access to affordable coverage and won’t foster dependency precisely because it isn’t an entitlement; that insurance should be more minimal than ACA proponents think it should be; and so forth. And they often make general versions of these arguments.
But the point is that many Republicans have deceptively refrained from being forthright about whether they support the specific policy outcomes those priorities would produce, particularly in the short term. Senators who are now expressing concern about losing their state’s expansions have been supporters of repeal. During the 2014 elections, multiple GOP senate candidates ran on repeal while dissembling and evading endlessly on whether they’d also support rolling back their state’s Medicaid expansions.
And then there’s Donald Trump. He has claimed that the replacement he champions will mean “insurance for everybody.” In his speech to Congress, he called for reforms that “expand choice” and “increase access” and “lower costs” while making “health insurance available to everyone.” Of course, Trump doesn’t really know much about health-care policy or care about the details. But he does know that he’s a winner and Obama is a loser, so his plan simply must and will deliver more than Obamacare for less. The CBO’s answer to that: Sorry, No.
The basic party-wide argument has been that if only Republicans could do away with the hated monstrosity of Obamacare, they’d be able to deliver a replacement that delivers health care to everybody (including the poor and sick) while lowering costs and cutting taxes and getting rid of Washington mandates — in other words, a plan that delivers the good stuff in the ACA without the bad. As long as repeal was not an actual possibility, Republicans could maintain this stance without having to create a plan that would accomplish this, or answer for that plan’s likely outcomes or the true priorities it reflects. Thanks to the CBO, that years-long dodge is no longer possible.
It’s hard to say whether this will end up forcing GOP senators to turn on the plan in large enough numbers to kill it. But at least it will be harder for them — and Trump — to evade responsibility for what their party’s plan would actually do.
The plan, the CBO concludes, would take more than $1 trillion away from programs targeting poor and middle-class families, to fund an $883 billion tax cut targeted at the wealthy … “No legislation enacted in recent decades cut low-income programs this much — or even comes close,” Robert Greenstein, the … president of the Center on Budget and Policy Priorities … says.
The biggest driver of that cut is the $880 billion in cuts to Medicaid — almost exactly the amount of the tax cuts, which overwhelmingly benefit the wealthiest.
“Throwing 24 million Americans off of health insurance, raising premiums for older low-income Americans, while giving $285 billion in tax breaks to the top 2% is a disgusting and immoral proposal. Thousands of Americans will die if this legislation is passed and we have to do everything that we can to see that is defeated.”
For some reason, it is considered out of bounds to discuss the actual consequences of policy in such overly blunt terms, but now we will get a real debate on exactly that.
The CBO says the clear losers would be older, low-income Americans between 50 and 64, just below the Medicare eligibility age. In other words, a lot of Trump voters … If Obamacare were still in place in its current form a decade from now, a 64-year-old earning $26,500 … would pay $1,700 for premiums in a year after accounting for federal assistance. Under the GOP plan, a 64-year-old at the same income level would pay $14,600 in premiums for coverage that would also have higher out-of-pocket costs.
The way the bill achieves those lower average premiums has little to do with increased choice and competition. It depends, rather, on penalizing older patients and rewarding younger ones. According to the C.B.O. report, the bill would make health insurance so unaffordable for many older Americans that they would simply leave the market and join the ranks of the uninsured. The remaining pool of people would be comparatively younger and healthier and, thus, less expensive to cover.
As noted above, many Trump voters might be the losers.
Kessler’s conclusion: “The process that led to the Affordable Care Act was lengthy and complex, but involved numerous hearings and ample time for public comment and input. Any suggestion to the contrary is ridiculous.”
* THE REAL LESSON FROM THE CBO REPORT: Paul Krugman is on point:
Obamacare is actually an intelligently designed system, and Republican claims that they could do much better even while slashing funding so they could cut taxes on the rich were always obvious nonsense. Trumpcare is a slapdash, incompetent piece of legislation; but even a much more competent set of people couldn’t have done better given the constraints of Republican Party ideology.
The key point here is that Republicans could keep the true implications of their ideological designs hidden, as long as actual repeal-and-replace remained a political impossibility.