This morning I’m trying to wrap my head around the cynicism and hypocrisy of the GOP health care bill, which was released last night. It preserves several of the most popular provisions of the Affordable Care Act, including allowing young adults to remain on their parents’ plan until the age of 26 and requiring insurers to cover those with pre-existing conditions. But in scrapping the individual mandate, killing the Medicaid expansion and eliminating income-based subsidies that help people buy insurance, the bill would rip away coverage from millions of people while doing nothing to keep costs down.
Republicans tout the “affordability” of their plan, but it looks to me that it will be just the opposite. Right now the ACA calculates subsidies based on age, income, and the cost of premiums in the local marketplace. The GOP bill would do away with these parameters and instead give flat tax credits determined by age bracket, from $2,000 for those under 30 to $4,000 for those over 60, even for higher-income earners who currently receive nothing under the ACA—up to $75,000 for individuals and $150,000 for couples. A 40-year old man in New Haven, CT with an annual income of $20,000 now receives a subsidy of $5,040 with the ACA. Under the Republican plan, his tax credit would decrease by 40% to $3,000, forcing him to come up with $2,040 out-of-pocket just to pay his premiums, assuming they stay the same. Many people receive additional subsidies to help cover the cost of copays; these would disappear. The GOP bill would give low-income people less financial assistance, while those who need it less would get more. It shifts money from the poor to the wealthy, all in the name of “affordability.”
The GOP bill would roll back the ACA’s Medicaid expansion by converting what is now an open-ended entitlement to a per-capita allotment to states. Funding wouldn’t necessarily rise as costs increase, and federal funding to states would be reduced starting in 2020.
In addition to “affordability,” the other watchwords that Republican lawmakers enjoy spouting are “freedom” and “choice.” In a tweet last month regarding the ACA, House Speaker Paul Ryan (R-WI) defined freedom as “the ability to buy what you want to fit what you need.” As his party sees it, if you want to spend your life not having health insurance, that should be your choice. Of course, all the GOP talk about “choice” is a smokescreen, because their plan does nothing to address it. Not having money to buy quality health insurance makes the lack of coverage not a choice, but an inevitability. In two other particularly egregious examples, Rep. Jason Chaffetz (R-UT) said, “You know what, Americans have choices … So maybe, rather than getting that new iPhone that they just love—and they want to go spend hundreds of dollars on—maybe they invest it in their own health care.” Last week, Rep. Roger Marshall (R-KS) told STAT News that some people “just don’t want health care.”
There’s no guarantee that the GOP bill in its current version will get through both houses of Congress. Conservatives dislike it because they think its subsidies are too generous, while four Republican senators have expressed misgivings about the rollback of the Medicaid expansion. And the Congressional Budget Office is still crunching the numbers to estimate costs and the number of people who will be affected. But it seems likely, given the bill’s provisions, that millions will lose their health insurance as it becomes unaffordable or they’re kicked off Medicaid rolls when states run out of money.
I find extremely disturbing the cruel cynicism of the GOP bill, as well as the contortions of lawmakers to spin it as an improvement over the ACA for the sickest and most vulnerable. What it reveals about our priorities as a nation is deeply troubling. It will make health insurance unaffordable for the vast majority of the 20 million Americans who obtained coverage under the ACA while shifting wealth to those who already have more. We are the only industrialized nation that does not have some kind of universal, single-payer health coverage for its residents; we have already signaled that we regard health care as a privilege for those who can afford it, not as a human right. The ACA has its problems, to be sure, but it has led to the lowest uninsured rates in American history. The Republican bill will increase wealth inequality, cause many to get sicker, and roll back the protections we have gained over the past six years of Obamacare.
Here’s some worthwhile additional reading: Sarah Kliff's summary of the bill in Vox, John Cassidy's commentary in the New Yorker, Jonathan Chait’s piece in New York Magazine’s Daily Intelligencer, and Michael Hiltzik’s blistering analysis of the GOP bill in today's Los Angeles Times. The Kaiser Family Foundation has excellent, in-depth coverage of health care reform, including interactive charts to calculate subsidies under the ACA and various GOP plans.