Having finally rolled out its legislative proposal to repeal and replace the Affordable Care Act, President Trump and the Republican leaders in Congress are scrambling to corral enough support to get the American Health Care Act (AHCA) through both houses of Congress with little or no Democratic support. Needing every vote they can get, the GOP leaders are promising “we won’t pull the rug out from under anyone.” That might be a promise they can’t keep.
When then-President Barack Obama was selling the Affordable Care Act to the American public in 2010, he promised: “if you like your healthcare plan you can keep it.” But his advisors knew that statement would come back to bite them. While it helped push the ACA through it would later be used as a cudgel against Obama and his fellow Democrats in a series of disastrous election cycles. In 2013, PolitiFact cited Obama’s promise as the “Lie of the Year.”
Obama’s staff knew that the law would require millions of Americans to give up their existing insurance plans and choose another that had richer benefits and higher premiums but let him make that promise repeatedly. Their justification: Those existing plans were too skimpy and didn’t provide people with the protection they need. They even tried that age-old DC spin of saying “what the President meant was…..” All true but far from convincing.
Why rehash such old news? Well, the new Republican majority in Congress and President Trump are walking dangerously close to that same line between truth and fiction. When they say they “won’t pull the rug out from under anyone,” the public and the media hear a promise that people who like being insured will keep being insured after the enactment of the new plan. The problem for the Republicans is the same one the Democrats faced in 2010 – that’s almost certainly untrue.
Most analyses of the Affordable Care Act find that between 20 million and 23 million Americans gained health coverage thanks to the law. A little more than half got covered by expanded Medicaid eligibility adopted in 31 states and the District of Columbia and paid for with federal dollars. The rest bought coverage on the Health Insurance Marketplace (a.k.a., HealthCare.gov) using subsidies provided by the federal government. As a result, according to the Kaiser Family Foundation, the percentage of Americans without health insurance dropped from 20.4% in 2013 to 12.8% in 2015, representing a 7.6 percentage point drop, or a 37% decline. The biggest declines occurred among Latinos and African Americans and in southern states.
The new GOP plan would phase out the extra Medicaid dollars and put a cap on the federal share of funding for that program going forward. The Obamacare subsidies – keyed to a percentage of the premiums charged in each region of the country – would be replaced with flat tax credits that top out at $4000.
While official estimates aren’t in yet, most analysts are predicting enactment of the AHCA will result in millions of Americans losing the coverage they got under the ACA. Estimates range as high as 15 million or more. Most of Washington is waiting for the official word from the Congressional Budget Office, which is analyzing the GOP plan as we speak. If the CBO estimates match the predictions of millions losing coverage the job of passing the AHCA – already a tough slog – becomes much more difficult. The small but influential group of Republican moderates in Congress will balk at the notion of their constituents losing insurance. The larger but more poorly organized group of ultra-conservatives are already unhappy that the bill keeps some key parts of the ACA in place and will jump ship if efforts are made to make it more generous. This puts Trump, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell in a box with few ways out.
If the GOP succeeds in passing the AHCA, most of the pain is delayed until 2020, when Trump and many in Congress will be running for reelection. The bill’s champions are hoping voters will have forgotten about the promise of a rug under their feet. If Obama’s experience is a useful model that wish isn’t likely to come true. Get ready PolitiFact!