The Washington PostDemocracy Dies in Darkness

A lot of Republican rhetoric on health care this weekend may haunt the party in 2018

After passing the revised health-care plan in the House on May 4, GOP lawmakers headed back to their home districts - often to face the ire of constituents. (Video: Reuters, Photo: Jabin Botsford/Reuters)
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It’s important to remember, when considering the Republican plan to overhaul Obamacare, that the only constituency that fervently supports throwing out the Affordable Care Act is Republicans. In the most recent Post-ABC News poll, three-quarters of Republicans supported repealing Obamacare, sure — but 9 in 10 Democrats and two-thirds of independents favored strengthening the existing law. The net effect, then, is that Republicans on Capitol Hill are trying to deliver a long-held promise to their base — while not alienating other voters who might come to the polls next fall.

When Quinnipiac University asked Americans for their thoughts on the Republican bill, the American Health Care Act, the results were not encouraging: Only 17 percent of Americans supported the legislation in late March — and that didn’t even include a majority of Republicans. The balance the GOP needs to draw, in other words, is a tricky one.

And that poll was taken well before the amendments that ultimately ensured the bill’s passage in the House last week — amendments that weakened protections for preexisting conditions. That facet of Obamacare is backed by majorities within every party, according to that Post-ABC poll. Even a majority of those who voted for President Trump last year think that holding costs down for those preexisting conditions should be protected.

The net effect of all of this? Republicans supporting the unpopular American Health Care Act have been forced, since its passage, to offer defenses of the bill that often defy the reality of what the measure would do. Since the House advanced the measure by a slim margin on Thursday, there have been a number of instances in which Republicans who backed it have offered inaccurate assessments of its effects.

Rep. Raúl R. Labrador (R-Idaho)

Labrador, no doubt to his chagrin, was the focus of a lot of attention after making comments about the health-care law during a town hall event in his district last Friday.

Rep. Raúl R. Labrador (R-Idaho) defended the GOP health care bill at a town hall in southern Idaho on May 5. (Video: Tom Hansen)

“Nobody dies because they don’t have access to health care,” he said — a claim that struck observers as obviously untrue.

A 2009 study from researchers at Harvard estimated that some 45,000 people die in America each year because of a lack of health insurance. Americans of working age without insurance, they found, had a 40 percent higher risk of death than their peers who were covered. However, this study has been criticized because it implies a causation between the lack of coverage and mortality. (It could be, for example, that there is some third factor that leads to people both having a higher likelihood of dying and lacking health-care coverage.)

Another study looked specifically at the effects of expanding Medicaid, an effort that was part of the Affordable Care Act. It determined that there was a 6.1 percent drop in deaths in states that expanded Medicaid (prior to the ACA) versus those that didn’t.

Speaker Paul D. Ryan (R-Wis.)

Ryan appeared on ABC’s “This Week” on Sunday, where he made several claims about preexisting conditions.

“Under this bill, no matter what, you cannot be denied coverage if you have a preexisting condition,” Ryan told host George Stephanopoulos. “And under this bill, you cannot only not be denied coverage —”

“But you can charge people more,” Stephanopoulos interjected.

“Let me finish my point,” Ryan continued. “You can’t charge people more if they keep continuous coverage.”

Perhaps the best explanation of why Ryan’s first point is misleading came from Matt Alsdorf on Twitter.

You’re guaranteed coverage if you have a preexisting condition under the American Health Care Act — but there’s not much of a guarantee that you’ll be able to afford it. “[W]e have all these multiple layers of protection” for those with such conditions, Ryan insisted: States must get waivers to allow insurers to increase premiums for those with preexisting conditions should there be a lapse in those patients’ coverage, and there will be pools of money meant to help keep costs down. But “multiple layers” of protection is less protection than exists under the Affordable Care Act — and is less than what Americans told our pollsters they hoped to see.

This issue more than any other exemplifies the trickiness of the Republican position. The change to preexisting condition coverage — from an absolute protection of coverage and cost to the “multiple layers” — was made to get conservative Republicans (like Labrador) onboard. Now, though, it’s poised to become one of the most politically tricky parts of the AHCA, alienating non-core supporters.

NBC’s Alex Seitz-Wald got a quote that exemplifies how those with preexisting conditions are reacting to the change.

“I have never canvassed before, but I will f—ing crawl door to door to make sure you lose,” voter Judith Casale said of her representative, Rep. Carlos Curbelo (R-Fla.), who voted for the bill.

Ryan, part two

Ryan made another comment to Stephanopoulos that’s worth noting.

“There wasn’t a CBO analysis of this bill,” the ABC host said, noting that Ryan demanded a score from the Congressional Budget Office before a vote on Obamacare in 2009. “Have you met your own standard here?”

“Yes,” Ryan replied. “I think this is a kind of a bogus attack from the left.”

His spokeswoman, AshLee Strong, argued on Twitter that the bill had indeed been scored.

The catch? It was last scored in March, before the amendments that ensured its passage — including the change to how preexisting conditions are covered. The bill that passed simply isn’t the same one.

Another analogy is in order here. Imagine that you are looking to buy a house that’s been appraised at $200,000. When you go to see the house at closing, you notice that all the wiring has been stripped out and the garage torn down. Sure, the house was appraised — but before substantial changes.

The analogy works the other way, too: Imagine the owner added a new addition and upgraded all the windows. Not the same house. But if an owner did that, you’d think that they’d wait for a new appraisal before selling it to you, no?

It’s particularly interesting that Ryan’s team is bragging about those CBO scores, since the estimates from the nonpartisan group found that some 24 million fewer people would have coverage in 2026 than under Obamacare. That number alone is likely responsible for the bill’s failure to advance in the House in March.

Tom Price, secretary of the Department of Health and Human Services

Price appeared on CNN on Sunday to discuss the $880 billion cut to Medicaid that’s included in the AHCA.

“That’s actually not going to result in millions of Americans not getting Medicaid?” CNN’s Jake Tapper asked.

“Absolutely not. We believe strongly that the Medicaid population will be cared for in a better way under our program,” Price replied.

About half of the decline in the population without insurance under the Affordable Care Act came from that expansion of Medicaid. Incidentally, the CBO report from March estimated how many fewer people would have coverage because of the funding cut: Some 14 million — more than half the total decline of 24 million.

Our fact-checkers went much deeper into Price’s comments, if you’re interested.

The argument from supporters of the American Health Care Act, then, goes something like this. Preexisting condition coverage is mandated (though affordability isn’t) and Medicaid cuts won’t reduce the number of people with insurance — but, regardless, a lack of insurance won’t result in increased fatalities.

That may prove a tough sell in 2018.