When Republicans unexpectedly won control of all branches of government in November, it was well understood that they hadn’t done the basic due diligence required to govern. This is what political commentators meant when they deployed the overused metaphor of the dog that caught the car.

The fact that almost everyone in the political world believed Donald Trump would lose the presidency explained the element of surprise. But the belief that he and his party would be unprepared stemmed from a widespread understanding that they had largely ignored for the realities of governing during the Obama years—particularly as pertained to their campaign against the Affordable Care Act.

As soon as the ACA became law in March 2010, Republicans began promising to repeal it, but they knew right away that the facts of the law, like its pre-existing conditions protections, would assert themselves quickly and they would need answers.

To say that coining the phrase “repeal and replace” was the full extent of the spadework Republicans have done since then would only be a slight exaggeration, but the truth is, they and everyone else would be better off if it were true. In addition to repeating this hollow slogan, Republicans drew a caricature of the Affordable Care Act based entirely on its shortcomings and tradeoffs; they scrubbed the law’s material benefits from their rhetoric, and made contradictory promises about how they would remedy these problems. These added up to a second caricature of a Republican health care plan that would be somehow cheaper than Obamacare, cover more people, and with better insurance.

House Republicans stand poised on Thursday to pass legislation that would—if it became law itself—expose the falseness of these promises. The fact that they will be voting, by design, without an impact analysis from the Congressional Budget Office (CBO) suggests that at a level of abstraction they know their bill, the American Health Care Act, has its own tradeoffs, all of which come at the expense of the most vulnerable—the sick and old and poor—for the benefit of the healthy and affluent.

But because Republicans wasted years before stitching and taping this vile bill together, most of them have no sense of its certain lethality.


Back in 2011, I wrote a story about how Obamacare’s coverage guarantee, and its ban on price discrimination against people with pre-existing conditions, weren’t just policy improvements, but a compact with the public. The expectation that chronically ill patients would be insurable in perpetuity would not just increase insurance rolls, but lay a foundation for medical decisions that, while life-saving, would leave them in need of constant treatment.

The article repurposed the term “death panels” to describe a very real problem—not just that most experts believe uninsurance and mortality are linked, and reducing coverage will lead to preventable deaths, but that ending the compact would interfere directly with ongoing care.

If, for instance, you got an organ transplant thanks to a health plan you bought on an ACA exchange, or through the ACA’s Medicaid expansion, and rely on expensive immunosuppressant therapy to prevent your body from rejecting the new organ, House Republicans will vote today to maybe kill you.

Six years ago, before Obamacare’s coverage expansion went into effect, the number of people in that predicament, or a similar one, was surely tiny. But the ACA has extended coverage to millions of people since then. If Republicans weaken protections for people with pre-existing conditions, make their insurance unaffordable as this bill promises to do, the toll will be disastrously high.

The insularity of conservative thoughts blinds many Republicans to this logical certainty. Just as so many Republicans lack the empathy to support things like marriage equality or disability rights until their families need the protections, they can not see that violating the pre-existing conditions promise is grossly inhumane. And because Republican members of Congress are all insured—and, indeed, they selfishly exempted themselves from the pre-existing conditions rollback—it will never dawn on them. In many cases, the GOP’s moral intuition runs backwards.

But that doesn’t mean Republicans don’t know what they’re doing in a broader sense. Though the CBO doesn’t forecast immediate mortality risks, it does estimate the global costs and consequences of legislation, and has already apprised Republicans that the AHCA would do widespread harm.

The changes Republicans have made to AHCA over the past several weeks have made the bill considerably more regressive and politically toxic, but have not altered its fundamental nature. The original AHCA failed amid a feeding frenzy over the CBO’s finding that the bill would strip insurance from millions of people within a year, and leave 24 million fewer people insured by the end of the decade, relative to current law.

Since then, GOP leaders have sought to address the concerns of members in both wings of their party, but have not altered the central bargain that made the initial CBO score so bad. All of the backroom dealing has tinkered around the edges of a House Republican consensus that it is good policy to finance a massive tax cut for the rich with savage cuts to Medicaid and to premium subsidies for working class people.

Recent amendments layer onto that consensus a new proposition that states should be able to allow insurance companies to price people with pre-existing conditions out of the insurance market, and sell people plans that don’t cover basic benefits like doctors visits and hospitalization. The Brookings Institution has persuasively argued that the AHCA would amount to near-wholesale elimination of Obamacare’s ban on discrimination against people with pre-existing conditions, and may even allow employers to hollow out employee health benefits.

The latest changes to the AHCA will likely adjust the CBO’s cost and coverage estimates, but will not provide Republicans any political relief. Republicans want to outpace the CBO because they know to a certainty the CBO’s findings will make it harder for them to reimpose what was a fundamentally immoral status quo.

What makes the effort to plunge ahead despite all of this knowledge so mystifying is that it will all catch up to them. If the political breathing room House Republicans have created for themselves by voting without a CBO score allows them to pass the AHCA, the CBO will weigh in after their votes have already been cast. If Senate Republicans respond to that score by shelving the bill, it will underscore how reckless and cynical their House counterparts were being by voting blind. If, on the other hand, the bill somehow clears the Senate, becomes law, and people start dying, the politicians who passed it will have to choose between claiming they didn’t know how devastating and immediate the consequences would be, or admitting that they were lying the entire time.