Republican House leaders have spent months dodging questions about how they would replace the Affordable Care Act with a better law, and went so far as to hide the draft of their plan from other lawmakers. No wonder. The bill they released on Monday would kick millions of people off the coverage they currently have. So much for President Trump’s big campaign promise: “We’re going to have insurance for everybody” — with coverage that would be “much less expensive and much better.”
More than 20 million Americans gained health care coverage under the A.C.A., or Obamacare. Health experts say most would lose that coverage under the proposal.
Let’s start with Medicaid. Obamacare expanded the program to cover 11 million more poor Americans in 31 states and the District of Columbia. The Republican bill would end the expansion in 2020. Although people who sign up before 2020 under the expanded Medicaid program, which covers people with incomes up to 138 percent of the federal poverty level (about $33,900 for a family of four), would be allowed to stay on, many would be kicked off over time. The working poor tend to drop in and out of Medicaid because their incomes fluctuate, and the Republican plan would bar people who left the expanded program from going back in.
Tom Price, secretary of health and human services, discussing the Republican bill to replace the Affordable Care Act. Credit Doug Mills/The New York Times
The bill would also, for the first time ever, apply a per-person limit on how much the federal government spends on Medicaid. This change could shift about $370 billion in health care costs over 10 years to state governments, according to the Center on Budget and Policy Priorities. Many state governments, faced with limited budgets, would be forced to cut benefits or cover fewer people.
For people who buy insurance on federal or state-run health exchanges, the G.O.P. plan would greatly reduce the A.C.A.’s subsidies, which come in the form of tax credits. For example, a 40-year-old living in Raleigh, N.C., who earns $30,000 a year would receive $3,000 from the government to buy insurance, 32 percent less than under current law, according to the Kaiser Family Foundation. The bill would provide older people more generous subsidies — those over 60 get a subsidy of $4,000, or twice as much as 20-somethings — but insurers would be allowed to charge older people five times as much as younger people.
The plan would do away with the current mandate that requires nearly everybody to obtain insurance or pay a penalty. (Instead, insurers would be allowed to charge people who don’t maintain their insurance continuously 30 percent more for coverage.) But because the legislation would still require insurers to cover pre-existing conditions, people would have a strong financial incentive to buy insurance only when they got sick — a sure way to destroy the insurance market.
House Speaker Paul Ryan and Tom Price, the secretary of health and human services, have railed against high premiums and deductibles for plans sold on the health exchanges, but that problem would only worsen under their proposal because insurers would almost certainly raise their prices as the pool of the insured shrank. Republican lawmakers seem to think that people who can’t afford insurance are simply irresponsible. Representative Jason Chaffetz of Utah, for instance, told CNN that people should invest in their health care, “rather than getting that new iPhone.” Word to Mr. Chaffetz: Health insurance costs more than $18,000 a year for an average family; an iPhone costs a few hundred dollars.
While working people lose health care, the rich would come out winners. The bill would eliminate the taxes on businesses and individuals (people making more than $200,000 a year) who fund Obamacare. The tax cuts would total about $600 billion over 10 years, according to the Joint Committee on Taxation.
House committees will start considering the bill on Wednesday. Even if it passes the House, some Republican senators object to the Medicaid cuts and the Tea Party wing hates the idea of retaining any subsidies.
Republicans have been vowing to repeal the Affordable Care Act even before it became law in 2010. But they still haven’t come up with a workable replacement. Instead, the G.O.P.’s various factions are now haggling over just how many millions of Americans they are willing to harm.