Now we have it — the long-awaited, Trump-Ryan “repeal and replace” antidote to the Affordable Care Act, a.k.a. Obamacare. It is called the American Health Care Act. There are two things to bear in mind. Well, rather a few more than two, but these are important.
The first thing is that, at its center, its nucleus, Trumpcare (or Ryancare, whatever) is not about health care. It is not about making health insurance affordable, or making health care affordable, not about insurance premiums or co-pays, not about purchasing health insurance across state lines. It is not about insurance exchanges, nor free market solutions, nor Medicaid. It is not about reimbursement rates, nor “access.” It is not about “freedom.”
The American Health Care Act is a tax bill. A tax reduction bill. It would reduce taxes by about $600 billion, though only a very few Arkansans would see any savings: about half the cuts would benefit households with incomes above a quarter-million dollars annually, and only those with investment income; under Obamacare the levy is a fraction less than four percent. The balance of the tax cuts would accrue to insurance corporations, drug companies and medical equipment manufacturers.
The second thing: Trumpcare, as presently constituted, has no chance of passage. Its prospects in the House, under the uncertain leadership of Speaker Paul Ryan, are grim — grim being sunny as compared to the certain death that awaits it on the other side of the Capitol. The Senate is, to borrow a phrase, a death panel, its judgment on Trumpcare already pronounced.
Interestingly, Arkansas’s Tom Cotton may have been the very first senator (or judge) to pass sentence on the bill, only hours after the Speaker brought it to the courtroom. Votes aren’t there, he said. What’s the rush? he asked. And let’s wait on the cost estimates from the Congressional Budget Office.
The wait ended the following day, and it was worse than the Trump-Ryan team had feared. Yes, if enacted, the plan would shave almost $340 billion from the federal deficit in the coming decade; but in the same period 24 million Americans would get a haircut: their health insurance would disappear.
Having anticipated a politically negative assessment from the CBO, the Republican leadership, House and White House, had begun challenging the numbers even before they were released. Mr. Trump’s health secretary was everywhere, assuring the spooked and the skeptical of his party that the calculations did not fully consider the administration’s three-step program for repeal-and-replace.
Cotton was not mollified. If anything he seemed even more irritated. The Ryan approach may be repeal, he snorted, but there’s no replace.
“There is no three-phase process. There is no three-step plan,” Cotton told a radio interviewer. “That is just political talk. It’s just politicians engaging in spin.”
Besides, Cotton said, you had to give opponents of the Ryan bill their due:
“They’re right that coverage levels will go down in the coming years under the House bill. They’re also right, I’m afraid, that insurance premiums will continue to go up in the near term, for three to four years, before they start perhaps falling in the long term. However, I suspect that the political consequences of those near-term changes means that the long term will never actually arrive.”
Those consequences, Cotton made clear, could include surrendering GOP control of the House to Democrats. Republican members, he advised, should decline to “walk the plank.”
The relative silence of Arkansas’s U.S. representatives suggests they understand the stakes. The First District’s Rick Crawford quickly dismissed the legislation as, essentially, a betrayal. With an important vote looming, the Fourth District’s Bruce Westerman, whose seat on the Budget Committee gives him a significant voice on the bill, was undecided. Cotton’s Arkansas colleague in the Senate, John Boozman, was expressing serious reservations as well.
Gov. Asa Hutchinson’s had announced his reservations at about the same time Cotton was dismissing Trumpcare. More flexibility was needed, Mr, Hutchinson said. More to the point, the Medicaid money the Ryan plan would scale back would soon enough blow his budget to smithereens. One suspects the Governor has spoken, with some urgency, to all six Arkansas delegates to Washington. And that every other Republican governor in those states that expanded their Medicaid programs, to take advantage of the billions in federal dollars Obamacare provided, had similar chats with their congressional delegations.
What will emerge from the confusion, from the rubble that already is the Trump-Ryan repeal-and-not-really-replace plan? From a U.S. House divided not only along partisan but intra-party lines? The best answer is, not much in the near term, and perhaps nothing very much beyond that.