Less than a day after it was released, the House Republicans’ Obamacare replacement bill, the American Health Care Act, seems bereft of friends. Barely lifting a finger in opposition, Democrats may enjoy the demise of the AHCA before it leaves the House.
Right-wing groups such as FreedomWorks oppose any bill that requires guaranteed government support for health care. Under Obamacare, this was the subsidies to buy through the exchanges; in the AHCA, is it the refundable tax credit. “This is ObamaCare-lite. It creates a new entitlement through the refundable tax credits,” says Jason Pye, FreedomWorks’s policy director. The group is hardly alone. ”We’re 100 percent behind the efforts of Rand Paul, Mike Lee, Ted Cruz, and the House Freedom Caucus to bring real patient-centered alternatives to replace ObamaCare, and we have endorsed Rand Paul and Mark Sanford’s ObamaCare Replacement Act, which sets the benchmark for a shift away from ObamaCare.” Heritage Action likewise slammed the effort because it “not only accepts the flawed progressive premises of Obamacare but expands upon them. Ronald Reagan once said, ‘Government’s view of the economy could be summed up in a few short phrases: If it moves, tax it. If it keeps moving, regulate it. And if it stops moving, subsidize it.’ The AHCA does all three.”
Phil Klein acknowledges that “despite the political failures that resulted from Obamacare, the clunky legislation still moved the ball ideologically to the left.” He observes, “The argument isn’t over whether the government should require all insurers to cover people with pre-existing conditions. The argument is about whether the government should pay for it by forcing healthy people to purchase insurance under the threat of a penalty, as Obamacare does, or by threatening anybody who doesn’t maintain continuous coverage with a 30 percent late fee, as the GOP prefers. Liberals, in other words, have won the central philosophical argument, and Republicans are reduced to fighting over the mechanics.”
Frankly, we do think the issue of government subsidized health care has been decided. Obamacare moved the goalposts and Americans now have an expectation of subsidized health care. Republicans can try to undo that expectation and sell something without guaranteed support, but I suspect it will lose the majority of Republicans in the Senate and maybe in the House. (President Trump likely would not have the nerve to defend such a bill that creates so many hard-luck stories.) FreedomWorks and the libertarian-ish lawmakers think the debate can still be won. I’m skeptical, but it is far from clear they will ever come around to supporting a bill they view as “Obamacare Lite.”
Then there are fiscally responsible House members balking at the notion they should vote for a mammoth bill without knowing its cost, coverage or budgetary impact. Outside groups are trying to do estimates. The Tax Foundation, for example, thinks that the AHCA would repeal 14 of 21 taxes, creating a question as to how the new bill will be funded. The Tax Foundation estimates that “rolling back the tax increases in the Affordable Care Act would reduce federal revenue by $574.5 billion over the period between 2017 and 2026. … The estimates also do not include the direct revenue effect of eliminating the individual mandate and the employer mandate.” Opponents think huge cuts to Medicaid will pay for it. The poor, in effect, get the worst end of the deal. House Speaker Paul D. Ryan (R-Wis.) says the bill is cheaper, but without the Congressional Budget Office scoring, we do not know if that is true. We certainly don’t know the CBO’s assessment of the number of people who will lose coverage.
A senior Democratic domestic policy adviser to a top House Democrat thinks these groups have a point. “The GOP’s bill is an exercise in cowardice. After running on this idea of repealing the ACA and the philosophy that the government has no role in providing health insurance, now that they have their chance they are hiding behind this mealy-mouthed, Obamacare-lite,” the adviser says. He also points out that the House bill delays “repeal of Medicaid and reform of Medicare until after the midterm elections to minimize their political fallout. These members who claim to be all about deficit reduction and getting our debt under control don’t even have the guts to get their bill scored by CBO before we vote on it.”
In addition, Republican moderates, primarily in the Senate but also in the House, will not stand for gutting Medicaid. Four have already opposed the draft House bill because it does not protect Medicaid recipients who gained coverage when Medicaid was expanded under Obamacare.
The real question is what Trump will do. He doesn’t like being on the wrong side of public opinion (which right now wants to reform but not repeal Obamacare), and he likes losing even less. He could well turn around, denounce the plan as failing to cover “everybody” and tell the House to try again. If he agrees with Senate moderates that the bill is not generous enough, a new bill may solidify and perhaps increase the number of conservative opponents.
In truth there is no magic bill that would please hard-line conservatives and GOP moderates. One side wants to roll back Medicaid; the other refuses. One wants government out of the health-care business even if more people wind up without coverage; the other side balks at the human cost. No bill can save money, improve care and expand choices without massive taxes and more government intrusion into the marketplace. By setting expectations far too high and crafting a bill so ungenerous to the poor, the House GOP has made failure more likely.