After years of insisting the Affordable Care Act was "rammed through" without Americans knowing what it would cost, House Republicans passed their own health-care plan on May 4, without an estimate of its impact from the Congressional Budget Office. (Jenny Starrs/The Washington Post)

House Republicans voted Thursday to repeal and replace the Affordable Care Act with their alternative plan, the American Health Care Act. This is a big political victory — and a big win for the Trump administration. However, it will likely create headaches for the Republican legislators who voted for it — and, depending on what happens next, Republicans more broadly.

Next, the AHCA may die in the Senate, where it faces a much tougher challenge, leaving House Republicans on the record as having cast a vote on an unpopular piece of legislation that went nowhere. Or some version of the AHCA may actually pass the Senate, garner Trump’s signature and become law.

Why the rush?

Why did House Republicans rush through a vote on a complex piece of legislation affecting millions of Americans and nearly a fifth of the U.S. economy without waiting for an analysis of its effects from the Congressional Budget Office?

One answer: Republicans were holding together a very fragile coalition of legislators. Any further information — such as Jimmy Kimmel’s emotional monologue about his newborn son’s heart condition — could erode public support for the already unpopular legislation. House leaders feared that would make it impossible to pass without still more amendments — or having to start over completely.

No matter what happens in the Senate, House Republicans face minefields

Most public discussion so far has been about how the AHCA will change the ACA’s most popular provisions like guaranteed coverage for people with preexisting conditions. But even unpopular provisions could cause problems. For instance, only 35 percent of the public supports the individual mandate — which requires everyone to have health insurance or pay an annual fine. But our research suggests that Republicans may face backlash even there, once opponents highlight what the AHCA uses to replace the mandate.

Insurance marketplaces need healthy people to pay for insurance, or insurers won’t have a pool of money to cover those who are sick. So how can healthy people be enticed into buying it? Subsidies (or “carrots”) are rarely enough, and therefore penalties (or “sticks”) are often used to ensure enough individuals are paying into the system. Repealing the ACA’s penalty may be popular now, but what will replace it?

So far, “Trumpcare” handles this by replacing it with a “continuous coverage requirement.” If you let your health insurance coverage lapse for more than 63 days, you would have to pay a 30 percent late-enrollment surcharge on top of the premium for the next year. (The bill passed with two amendments affecting these penalties. The widely debated MacArthur amendment lets states seek waivers to enable insurers to charge higher premiums to people with preexisting conditions who fall into this coverage gap. The late-breaking Upton amendment added Wednesday provides $8 billion in funds to offset some of these higher penalties for waiver states, but most analysts don’t think it’s enough).

As we’ll explain, the penalty for lapsed enrollment in nonwaiver states will likely be quite unpopular.

How we studied public responses to information about health insurance enrollment penalties

From March 10 – 16, during the debate over the first version of the AHCA, we fielded a survey experiment on a nationally drawn sample of 1,588 Americans. Participants were asked to read a short news excerpt about both the ACA and the Republican plan to repeal and replace it. We randomly varied the excerpt. Some respondents got only basic information: that the ACA, also known as Obamacare, was passed into law in 2010 and that Republicans in Congress were currently trying to repeal and replace it with the AHCA. Others also learned about the ACA’s individual mandate and the tax penalty for not enrolling. A third group read the same text about the ACA penalty and also read about the AHCA’s proposal to replace the tax penalty with the 30 percent enrollment-gap penalty.

We asked respondents whether they had a generally favorable or unfavorable view of the ACA and of the AHCA and then whether they preferred the ACA or the ACHA (respondents were allowed to check “neither”). We also asked about what they knew about ACA and AHCA components, so we could assess public awareness of their policy details.

ACA tax penalty is well known, AHCA enrollment gap penalty is largely unknown

By March 2017, people were well aware that the ACA requires nearly all Americans to have health insurance or pay a penalty to the government. In the group that got only basic information about the ACA, nearly three in four correctly identified the tax penalty as part of the ACA. That’s more than knew about any other components, including subsidies for low-income citizens.

But only 28 percent knew that the AHCA would penalize enrollment gaps. That’s fewer than knew either that the ACHA would repeal the subsidies; how the law would treat preexisting conditions; or that young adults under 26 could stay on their parents’ insurance.

Highlighting the AHCA’s penalty erodes its support

Emphasizing the ACA tax penalty has no effect on whether respondents favor the ACA, even when we adjust for key demographics like partisanship and voting for Trump. But telling respondents about the AHCA’s enrollment gap penalty makes them less enthusiastic about the GOP bill. When asked explicitly which they prefer, respondents told about both the ACA’s tax penalty and the AHCA’s enrollment gap penalty are more likely to prefer the ACA.

The CBO report may have lowered support for the AHCA even further

Because we were surveying respondents both before and after the Congressional Budget Office released its score for the AHCA’s first iteration, we can check whether the report affected public opinion. In short: yes. Even after adjusting for a time trend, after the report was released, respondents were less favorable toward the AHCA.

As much as citizens don’t like the requirement to purchase insurance or pay a penalty to the government, our evidence suggests that they dislike the AHCA’s penalty paid to insurers even more.

In short, AHCA opponents and potential challengers to House Republicans can choose from among many lines of attack: the public is already concerned about protections for people with preexisting conditions, huge cuts to the Medicaid program, and citizens losing insurance. Highlighting the AHCA’s coverage-gap penalty could drop public support further.

Erika Franklin Fowler is an associate professor in the department of government at Wesleyan University, specializing in political communication.

Courtney H. Laermer is a biology and government double major at Wesleyan University and a supervisor for the Wesleyan Media Project.

Laura M. Baum is project manager of the Wesleyan Media Project at Wesleyan University in Middletown, Conn.

Sarah E. Gollust is associate professor in the division of health policy and management at the University of Minnesota School of Public Health, researching the politics of health policy, particularly the role of the media and public opinion.

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