“I am opposed to the American Health Care Act (AHCA) in its current form,” said Dean Heller, who may be the most vulnerable Senate Republican up for reelection in 2018. “This bill does not do enough to address Nevada’s Medicaid population or protect Nevadans with pre-existing conditions.” Bill Cassidy agreed: “Congress’s focus must be to lower premiums with coverage which passes the Jimmy Kimmel Test. The AHCA does not.” (The “Jimmy Kimmel test” would be that no one is denied coverage because of his or her income.)
But here’s their quandary: As much as they might like to distance themselves from what the House did, the AHCA has made their job even harder, creating problems they may have no way to solve.
Why is that, if they’re starting fresh? The reason is that House Republicans, through a combination of bottomless cruelty and PR bumbling, have completely transformed the health-care debate.
To begin with, they succeeded in making the Affordable Care Act popular, something Democrats never managed to achieve in the seven years since it passed. They did so by threatening to take things away from people, activating their natural loss aversion (the tendency to intensely fear losing what you have) and bringing attention to the parts of the Affordable Care Act (ACA) that are most popular. Consider, for instance, the question of preexisting conditions. When we were debating the first version of the AHCA, it was part of the discussion but it didn’t dominate it, since that bill included only a roundabout assault on the protections the ACA affords the tens of millions of Americans who have a medical history that in the bad old days would have gotten them denied coverage.
After that first version failed, Republicans succeeded in securing support from the ultra-right Freedom Caucus for the second version in part by inserting a provision allowing states to opt out of the preexisting condition protection. When they did that, preexisting conditions suddenly became the single most important element of the discussion.
And while Republican senators might try to dismiss the CBO score, it won’t be easy, because what the score (and the news coverage it receives) does is turn complex policy problems into acute political problems, by making things very concrete. The CBO says: The effects will be A, B and C. That then arms Democrats with a series of talking points they’ll repeat over and over, which have the benefit of nonpartisan backing. For instance, how many times have you heard Democrats say, “24 million people will lose coverage!” since the first CBO score was released? About a zillion, right? The figure for the latest version of the AHCA is 23 million, but both numbers are vivid and shocking.
Democrats will also be able to point to passages such as this one in the latest CBO score, which, after noting that premiums for young and healthy people could be reduced, says this:
However, over time, less healthy individuals (including those with preexisting or newly acquired medical conditions) would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all.
The message in the CBO report is that young and healthy people will benefit, but older people or those who have preexisting conditions will be in big trouble. Or how about this passage:
People living in states modifying the EHBs [essential health benefits] who used services or benefits no longer included in the EHBs would experience substantial increases in out-of-pocket spending on health care or would choose to forgo the services. Services or benefits likely to be excluded from the EHBs in some states include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits. In particular, out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services. Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state.
That sounds pretty awful, doesn’t it? And keep in mind that Republicans have been using people’s displeasure over high out-of-pocket costs as a bludgeon against the ACA, while not mentioning that their plans would all increase out-of-pocket costs, particularly in the form of high deductibles for bare-bones plans. These and other points the CBO makes will continue to frame the news coverage of the issue, focusing everyone’s attention on a particular set of questions.
Democrats are already zeroing in on those points. As Sen. Patty Murray (D-Wash.) said in a statement responding to the CBO score: “Under Trumpcare, patients and families are going to face higher costs around every corner.”
As a result, Republicans in the Senate can’t fudge or gloss over anything related to those issues. So here are some questions Republicans are going to have to answer as they formulate their plan, whether they want to or not:
- How many people are going to lose coverage under your plan?
- What happens to those with preexisting conditions? Is their coverage guaranteed? Do they have to jump through a bunch of hoops? What happens if you have a preexisting condition and lose your job?
- How much does your plan cut Medicaid?
- Are out-of-pocket costs, including deductibles, going to rise?
- Are you bringing back yearly and lifetime limits on coverage? And wouldn’t that threaten even people who are covered through their employers?
These are questions Republicans really don’t want to answer, because when they do, the response from most Americans upon learning what the GOP plans would actually do is, “Oh, hell no.”
Now here’s the real problem the Senate faces: A plan built on conservative principles of minimal regulation and minimal government-provided insurance can’t solve these problems, by definition. The market won’t guarantee coverage for those with preexisting conditions; only government can do that. The market can’t provide real coverage for people with low incomes; only government can. We’ve seen some attempts by Republicans to change the questions around which this debate is revolving — House Speaker Paul Ryan keeps insisting that if 23 million people lose coverage it would be something to celebrate because it would mean they’d be exercising their freedom of choice — but those efforts have failed. The debate is now established on liberal terms.
That means Senate Republicans are left with two choices: Write a conservative plan like the one the House produced, which will be spectacularly unpopular, or write a plan that looks a lot like the ACA with just some minor tweaks here and there. They’re brainstorming to see whether they can devise a perfect solution that is true to their beliefs and that the public will embrace. The problem is it doesn’t exist.