The Washington PostDemocracy Dies in Darkness

This is not the health-care bill that Trump promised

After years of insisting Obamacare was "rammed through" without Americans knowing what it would cost, Republicans passed their own plan - without a CBO score. (Video: Jenny Starrs/The Washington Post)
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It was one thing for Donald Trump to pledge on the campaign trail that his plan for health care would assure that every American had coverage. He did so repeatedly, including during a town hall event in February 2016 at which he said his promise to “take care” of everyone might sound as if he was talking about a single-payer system, but he wasn’t. “That’s not single-payer,” he said. “That’s not anything. That’s just human decency.”

It was another thing, though, for Trump to make similar claims after the election. Before the election, it was anything goes in a way that most politicians would avoid. Afterward, one might expect Trump to zero in on his preferences a bit more narrowly, to scrape away the rhetoric and describe, instead, what it was that he wanted to see.

“We’re going to have insurance for everybody,” Trump told The Washington Post’s Robert Costa and Amy Goldstein during an interview less than a week before his inauguration. Although Trump was characteristically confident and equally characteristically light on specifics, he did outline several things that he anticipated the Republican replacement bill for the Affordable Care Act might include.

The plan would have “lower numbers, much lower deductibles.” The “philosophy in some circles that if you can’t pay for it, you don’t get it”? Trump insisted that “that’s not going to happen with us” — implying that there would be universal coverage regardless of income. What’s more, people could “expect to have great health care” that would be “in a much simplified form. Much less expensive and much better.”

Trump told Costa and Goldstein that people wouldn’t keep their existing plans but would have some sort of insurance plan. “[T]hey’ll be beautifully covered,” he said. “I don’t want single-payer. What I do want is to be able to take care of people.”

That is not the proposal that passed the House on Thursday.

The American Health Care Act, passed on the strength of 217 Republican votes, is another beast entirely. The bill would overhaul the Affordable Care Act, cutting Medicaid spending and changing the incentive structure to reduce government subsidies and eliminate the individual mandate.

How does it stack up to Trump’s January pledge?

Trump promised insurance for everybody.
The AHCA would probably result in 24 million more uninsured people by 2026, according to the Congressional Budget Office’s analysis of the original GOP bill.

Trump promised lower “numbers” and lower deductibles.
The AHCA would probably have higher deductibles. The CBO anticipates that they will be higher under the AHCA than they would have been if the ACA were kept, thanks to a change in the actuarial values used in determining plan costs.

Trump promised “much less expensive” coverage.
The AHCA would probably mean that customers would eventually see lower premiums — after premiums increased,  after premiums increased, pricing patients with higher costs out of the market.

Trump promised that people who can’t pay for coverage would still receive coverage.
The AHCA would probably reduce the number of lower-income people with coverage. This is in part because they will receive less government support to pay premiums. It’s also in part because the Republican bill cuts funding to Medicaid, meaning that millions fewer people would be covered under the program.

Trump promised that policies would be “much better” and that people could expect to have “great health care.”
The AHCA would probably reduce the quality of insurance plans, thanks to late amendments that would allow states to get waivers so that insurers could separate coverage items out of the default package. The cost of plans would go down — but people who find themselves needing coverage for something that had been removed would end up paying much more.

This is only the set of promises Trump made to The Post in January. He made other commitments even after inauguration that haven’t been met. He pledged repeatedly to protect funding for Medicaid, which is threatened under the AHCA. Just last week, he made another explicit promise.

Trump promised that the plan would take “care of preexisting conditions.”
The AHCA would probably increase costs for a substantial number of people who have preexisting conditions, as our fact-checkers noted Thursday.

Trump’s promise to cover everyone more broadly and for less money was always an impossibility, akin to saying that you were going to have your cake, eat your cake — and give everyone in America the same cake, which would feed them forever. But based on the comments he made at the unusual Rose Garden ceremony to celebrate the passage of the House bill, it’s still not clear that he admits that what was passed diverges from what he promised.

“As far I’m concerned, your premiums, they’re going to start to come down,” he said to applause. He later added, “Yes, deductibles will be coming down.” Again, this is not what outside analysis completed in March suggests will happen. Granted, the CBO hasn’t conducted a review of the amended AHCA, since the Republican majority pressed forward on a vote before it was complete. It’s unlikely, though, that the changes made in the past seven days would achieve the goals Trump promised again today.

He said something else, though, that may explain his overall strategy.

“Make no mistake,” the president said at one point, “this is a repeal and a replace of Obamacare, make no mistake about it. Make no mistake.” The bill would significantly alter it, but it isn’t a repeal-and-replace of the Affordable Care Act. Of all of Trump’s pledges on health care, though, that was his most consistent. “Repeal and replace” summarized the true extent of his desired outcome so fully that it was the only health-care point articulated on Stephen K. Bannon’s infamous whiteboard. No details about the repeal. None about the replace. Just … Repeal. Replace.

All Trump needs to do now is to convince America that this is what the AHCA does. Or at least, convince himself.