The American Health Care Act restructures a system of tax subsidies that have helped millions of working Americans who don’t get coverage through an employer.
President Donald Trump and House Speaker Paul Ryan are scrambling for votes to get the American Health Care Act — their replacement for Obamacare — and may have cobbled together enough sops to the far-right Freedom Caucus and sweeteners to Republican moderates to cobble together a majority in the House. But the end result is legislation that is, if possible, even worse than the original, failed bill.
For starters, it would not, as President Trump promised, cover pre-existing conditions "beautifully." An amendment that won the support of much of the Freedom Caucus would allow states to seek waivers to the Obamacare rule that prevents insurers from charging sick people more than healthy people in the same age bracket. States might not have much of a choice about the matter. Because the legislation also eliminates the requirement to have insurance (and the penalties for those who don't), and because it also reduces assorted subsidies to make coverage more affordable for lower income people, state insurance exchanges are almost certain to experience tremendous strain. To avoid a collapse, even Obamacare-friendly states might be forced to seek waivers.
The Republican answer to that is for waiver states to establish high-risk pools in which sick people could buy coverage. There are a few problems with that. Such pools have typically not been funded sufficiently to make them genuinely affordable, and it's unclear whether a last-minute, $8 billion boost in funding for them included at the behest of influential moderates will solve that problem. Even so, some people who are sick but not sick enough for the high-risk pools would likely be unable to afford coverage on the exchanges.
Meanwhile, the awful elements of the first iteration of Trumpcare remain. Medicaid, the health insurance program for the poor, would actually cover fewer people than it did before Obamacare. About 14 million people would lose their health insurance as a result. (What the new version of the AHCA would do to levels of coverage in general we don't know. Rather than cope with another round of bad headlines like when the Congressional Budget Office estimated that 24 million fewer people would have coverage after a decade under the first version of Trumpcare compared to existing law, House leaders are opting to move forward without a new score from the CBO.)
In the short term, premiums are expected to go up under Trumpcare but would eventually be somewhat lower than those under existing law. That aggregate analysis masks a lot. Young, healthy people might see their premiums go down, depending on where they live and other factors, but older consumers would generally see higher rates. And cuts to premium subsidies — one of the chief ways the AHCA is supposed to lower government costs — may make coverage less affordable even if rates are, on paper, lower.
Compounding the insanity of the House rush to vote on the AHCA is the fact that it stands little chance of passage in the Senate. Republicans have a 52 seats in the upper chamber of Congress, so they can lose no more than two votes to pass a repeal plan. Republicans in the House have had trouble enough in maintaining votes from both the moderate and conservative wings of the party, but the problem is compounded in the Senate, none of whose members have the luxury of a safely gerrymandered seat. Moreover, under Senate rules, only legislation directly related to the federal budget can be exempted from the possibility of a filibuster. Elements that were crucial in winning over the Freedom Caucus in the House, notably an end to the requirement that policies include certain kinds of coverage, don't qualify.
President Trump seems unbothered by these details. He continues to promise on Twitter "much lower premiums & deductibles while at the same time taking care of pre-existing conditions," and at a Rose Garden event Tuesday, he breezily addressed Republican members of Congress, "How's health care coming, folks, how's it doing — all right? We're moving along? I think it's time now, right?" The point for Mr. Trump isn't to achieve any particular policy objective. It's not even to get a bill through the Senate and signed into law. It's to be able to claim a win of any kind. His failure to get even a vote on the first iteration of the AHCA was a big embarrassment to him, and he's desperate to avoid a repeat.
But to the public, this means a lot more than a win or a loss for Mr. Trump. As the response to late night talk show host Jimmy Kimmel's Monday night monologue about his son's pre-existing condition shows, this is literally a matter of life or death.