The American Health Care Act has managed to become the least popular aspect of the Trump government despite the fact that the ethical and legal scandals surrounding the president himself have largely obscured something remarkable: The central justification for the Republican health care bill is a lie.
Every legislative initiative is presented to the public as an attempt to solve some genuine problem or advance some credible moral cause. The Affordable Care Act, aka Obamacare, was devised to address problems like widespread uninsurance, medical bankruptcy, the failure of the individual insurance market, and unsustainable growth of health care costs. The many bills that have been drafted over the years to price greenhouse gas emissions were meant to reduce the unacceptable risk of runaway climate change. The first Bush tax cuts were initially presented as a means of returning budget surpluses to taxpayers, then as a means of fending off a recession. Neither rationale honestly conveyed why Republicans sought permanent, regressive tax cuts, but at least the budget surpluses and the recession actually existed.
The AHCA, according to House Speaker Paul Ryan, is a “rescue mission” to save Affordable Care Act beneficiaries from the system’s inevitable collapse. That premise is so commonly held on the right—and so commonly repeated as though it were incontrovertible—that it’s seldom challenged by the press. It forms the strategic basis not just of plans to repeal the ACA, but of plans to leave it in place for now.
It is also completely false. The main public justification for the Republican Party’s top legislative priority isn’t some fact-based pretext, like the justifications for the Bush tax cuts, but a complete fabrication.
This is not to say that many ACA marketplaces don’t have challenges, some of them serious. But the AHCA isn’t what anyone credible would formulate as a solution to those problems. If Republicans intended their health care bill to be a “rescue mission” for those who live in markets with zero or one insurers, it would be a targeted bill, rather than one that would disrupt and perhaps destroy ACA marketplaces that are functioning well.
The disingenuousness of Republican efforts to pass this bill—which would render many insurance markets dysfunctional, and suck a trillion dollars out of the health care system—is now manifesting as a direct assault on expertise in government and policymaking. And the most distressing thing about it is that the stakeholders with the most influence over GOP legislators—the power to stop a bill they know is bad for the public interest, and to clarify that the ACA isn’t collapsing on its own—are largely content to let them get away with it.
Brad Wilson, the president and CEO of Blue Cross Blue Shield of North Carolina, is the exception that proves the rule. He’s seeking to increase premiums for ACA plans 22.9 percent—significantly more than the 8.8 percent he says he’d seek if Republicans weren’t injecting immense uncertainty into markets across the country.
In an interview with The Washington Post’s Greg Sargent last week, Wilson sourced the proposed rate increase specifically to the fact that the Trump administration won’t promise to meet the government’s cost-sharing obligations, which allow insurers to reduce out-of-pocket costs for poor and near-poor beneficiaries, and congressional Republicans won’t force Trump’s hand.
“The failure of the administration and the House to bring certainty and clarity by funding [cost-sharing reduction payments] has caused our company to file a 22.9 percent premium increase, rather than one that is materially lower,” Wilson said. “That will impact hundreds of thousands of North Carolinians.”
The difference between a stable ACA and a wobbling or downward-spiraling ACA, in other words, isn’t the destroy-the-village-to-save-the-village provisions of the American Health Care Act, but quantifiable sabotage by Republicans running the federal government.
You would never know this if you were basing your views of the AHCA, and the purposes it’s meant to serve, on the ambient media environment. Amy Walter of the Cook Political Report tallied up TV advertising for and against the ACA in 2010, and for and against the AHCA today, and her findings are extremely revealing. While opponents of the AHCA have aired more ads than proponents of the AHCA, the ratio is a not-terribly-lopsided 57 percent to 43 percent. Back in 2010, the ACA was swamped by an opposition campaign that out-advertised ACA supporters by a 9-to-1 margin.
In a way it’s some kind of miracle that the ACA ever clawed its way to popularity, or that the AHCA is so much more unpopular than the ACA ever was.
The history of the ACA, and the Clintoncare efforts of the early ’90s before it, show us that the health care industry knows how to fight and even defeat legislative efforts that threaten what they perceive to be their interests. Wilson speaking out bluntly is useful for journalistic purposes, and for his own interest in leveraging the Trump administration, but underscores just how timid the broader industry has been in the face of a multifaceted assault on a flawed but fixable insurance market. Insurance companies may not pine for the pre-Obamacare status quo, but they apparently don’t want to ruffle the feathers of the leaders of a unified government, especially a retributive president who could train his sights on them.
We have seen no profusion of Harry and Louise–style scare ads warning the public of the chaos Republicans are threatening to unleash in American health care, either by passing the AHCA or freezing cost-sharing payments to bring about the ACA’s collapse.
To the contrary, the opposition to the AHCA appears to be an outgrowth not of industry advocacy, but of news reports and consumer backlash to non-partisan analyses of the bill, which show it would uninsure over 20 million people and eliminate protections for people with pre-existing conditions in many parts of the country. There is no death-panel style agitprop for Republicans to contend with, so instead they are able to deploy agitprop of their own, including to neutralize the dispassionate findings of the Congressional Budget Office.
Last week, the Department of Health and Human Services—the department that is supposed to administer the ACA—counter-programmed CBO with an anti-Obamacare propaganda paper purporting to show premiums have soared under the ACA, without accounting for the fact that ACA plans are regulated to cover essential services, and subsidized to shield beneficiaries from premium increases.
Senator John Cornyn, a member of the GOP leadership and the tight-lipped working group modifying Trumpcare behind closed doors, called numbers pulled directly from the CBO’s report “fake news.”
In attempting to swindle Trumpcare into law, Republicans have relied on more than just false pretenses. They have sought to corrupt and discredit arms of government that were established to fight false pretenses with truth. It is another scandal marked by secret meetings, violated norms, collusion, and deceit. The public is outraged about it. But most of Washington has decided not to care.