Is Trumpcare Already Dead?

The rollout of the GOP’s long-awaited Obamacare replacement, the American Health Care Act, was a disaster. Instead of unveiling the bill with fanfare, it was leaked to the media on Monday night, which meant that there was precious little spin to help conservatives digest it. The following morning, Representative Jason Chaffetz of Utah went on TV to play pitchman, and ended up dominating headlines by telling poor people they have to choose between a smartphone and health insurance. President Donald Trump embraced the bill, but also left a lot of daylight, creating an opening for congressional Republicans and conservative activists to criticize it. Secretary of Health and Human Services Tom Price tried to patch things up by appearing at Press Secretary Sean Spicer’s midday lie jamboree, but came across as squirrelly and unprepared—his main argument for the bill was that it was short, as he stood next to a very tall stack of papers meant to represent Obamacare/big government. By evening, prominent Republicans were proclaiming that the AHCA was DOA and conservatives in the House were in revolt. “I don’t think it’s ever going to arrive in the Senate,” Kentucky Senator Rand Paul told CNN. “I think it’s dead on arrival in the House.”

The AHCA has achieved one thing in its short and worthless life, however: It sucks so much that people have come together from across the political spectrum to proclaim just how much it sucks. Paul branded it “Obamacare Lite” and tweeted (hurriedly, it seems): “It will not pass. Conservarives [sic] are not going to take it.” House Minority Leader Nancy Pelosi (D) said it would “Make America Sick Again.” Heritage Action CEO Michael Needham, who is scary conservative, said it “not only accepts the flawed progressive premises of Obamacare but expands on them.” Senate Minority Leader Chuck Schumer (D) tweeted that it “forces millions of Americans to pay more for less care.” Reason’s Peter Suderman wrote, “This bill, and the aura of secrecy surrounding it, seems more like a wish and a hope that this essential problem goes away rather than an attempt to truly solve it.” The Club for Growth saw an opportunity to own House Speaker Paul Ryan, dubbing this “warmed-over substitute for government-run health care” as “RyanCare.” And the Cato Institute’s Michael F. Cannon wrote, “This bill is a train wreck waiting to happen.”

Ordinarily, a botched rollout like this would have a silver lining. The problem, pundits and politicians would argue, is with the execution, not with the underlying goal. The rollout of Healthcare.gov in 2013 under former President Barack Obama, to name a related example, was a disaster, but eventually it did what it was supposed to do. The problem with the American Health Care Act, however, is one of conception. There is no vision for what Republicans ultimately want to achieve, after all the hurdles and hot-take criticisms and Chaffetz-like gaffes are overcome. Despite railing against Obamacare for years, Republicans seem to have no idea what the purpose of health care reform is in the first place.

Republicans may agree that the bill stinks, but for vastly different reasons. Some, like the American Enterprise Institute’s Joe Antos, criticized the bill because it would be a political and moral and public health disaster and would cause 10 million to 15 million people to lose their health insurance over the next 10 years. (Some estimates are even higher!) If you think that health care is an entitlement, which is something that Democrats and Donald Trump seem to agree on, this bill is a disaster: It would make coverage more expensive and decrease quality of care.

The counterargument provided by Tom Price is that the bill would offer more choice—you can pick your own doctor! But choice is a secondary concern. People want better care at lower prices, and this bill provides worse health care for higher prices. Perversely, by exchanging Obamacare’s subsidies for an ill-conceived tax credit plan, the AHCA would disproportionately affect the poor and the elderly, which you can see in this handy graphic by Axios Presented By U-North. The AARP, aka the GOP’s base of old people who need health care, isn’t happy and is already cutting ads against the AHCA.

Buying insurance across state lines—touted by both Price and Trump as a fix-it—could make health care cheaper, but it would also undoubtedly make it worse. A company in, say, Delaware could carve a niche for itself selling garbage health care at cut-rate prices. More importantly, if health care regulation was left up to the states then it would create a regulatory race to the bottom and a state with the worst regulations would end up cornering a big chunk of the market.

The AHCA’s proposal to cut back Obamacare’s Medicaid expansion—perhaps the best part of the flawed and, yes, conservative Affordable Care Act—has also received a host of criticism from people on both sides for taking health care away from hundreds of thousands of the most vulnerable people in this country, many of whom live in states with Republican governors.

But the bill is not only a disaster for those who think that health care is an entitlement—it’s also a disaster for those who believe in more market-oriented approaches. Here’s conservative writer Matt Lewis at The Daily Beast, for instance:

The current plan (and it hasn’t even gone to committee for markup yet) keeps the provision covering people with pre-existing conditions, but ends the individual mandate. This, alone, should sound alarm bells: You can’t stop sick people from signing up, and you can’t make healthy people sign up.

Refundable tax credits are also included, which means that people who do not currently pay any income taxes will be given free money as an incentive and a means to obtain coverage.

Many conservative think tanks—Heritage and Cato foremost among them—along with many Republican congressmen dislike the bill for this reason. As Vox’s Ezra Klein notes, it’s a shockingly regressive bill—the poor would pay much more for coverage than the middle class and wealthy—but there are still enough incentives in this bill for conservatives who are fundamentally opposed to the welfare state to turn up their nose. This has created a bizarre situation in which those who think that the government has practically no obligation to help citizens get health care and those who believe in universal health care are essentially united in opposition.

The AHCA is most notable for being mealymouthed. It dismantles aspects of Obamacare, but halfheartedly and in such a way that is clumsy and hurts poor, old people. Even the repeal of the dreaded individual mandate—the most demonized aspect of Obamacare—is undermined by a proposed fine for those who don’t have continuous health care coverage. The AHCA will punish you when you’re sick and need health care, not when you’re healthy and free-riding the system.

The simplest reason for this is that Republicans are unprepared. Republicans ranted about repealing and replacing Obamacare because it was good politics, not because they actually had any ideas about how to fix the health care system. Because no one thought Donald Trump would actually win, no one bothered to come up with a plan. When he did, they were the proverbial dog that caught the car—this terrible, hastily conceived plan is a testament to how craven and dishonest Republican opposition to Obamacare has been since its inception.

But the AHCA is also a shambles by design. The best explanation for the AHCA’s many flaws may simply be that Republican leaders are struggling to come up with a conservative alternative to Obamacare that doesn’t turn the health care system into a Darwinian nightmare. Though its impact would be deep, it’s actually superficial reform, roughing Obamacare up and kicking some poor people off health insurance in the process so that Republican leaders can claim they’ve repealed and replaced Obamacare, even as they leave some of its pillars in place.

For now, the AHCA probably doesn’t have the votes to make it through Congress. But don’t underestimate the cravenness of the Republican Party. The Wall Street Journal editorial board, for one, is calling for Republicans to pass it anyway. “The House bill is the only heath-care show in town,” they write, adding, “Republicans have a limited window for repeal and replace, and this is a once-in-a-generation opportunity.”