Numerous right-wing outlets (including the National Review) have been characterizing liberal criticism of the new healthcare bill passed by the House — specifically its abandonment of people with pre-existing conditions — as a “lie” from “the Left” (this particular iteration comes from Townhall.com).
I speak from no authority as a policy wonk or expert. Like most of us, I remain bewildered by the healthcare system and the complexities of its peculiar troubles in the United States. But, as I understand it, the new bill passed by the House allows states to opt out of the Obamacare rule prohibiting insurance companies from denying coverage (or charging higher premiums) to people with pre-existing conditions. So, certainly, loss of protection for pre-existing conditions is a potential outcome of the bill (even if not a direct provision/demand of it) — perhaps a quite likely one, given the other provisions of the bill.
The point of the Obamacare provision (again, as I understand it) was to insure that plans had good benefits and were available to everyone. Until the ACA, insurance companies had been brilliant about finding ways to avoid paying for expensive health care: denying coverage for pre-existing conditions, selling stripped-down plans that covered some things but not others, like, for example, prenatal or mental health care, or in some cases even prescription drugs. Insurance companies did this, of course, because their ultimate motive is profit. Obamacare, whose motive is healthcare for citizens, includes a list of categories that all insurers are required to cover — including the above and more. The new GOP bill eliminates that list.
The GOP bill also eliminates the individual mandate (requiring everyone, including younger and healthier people who might otherwise skip it, to buy insurance and thus keep premiums manageable for everyone), a provision first initiated by “Romneycare” in Massachusetts — it was originally a Heritage Foundation idea — and upheld by the Roberts court. And the GOP bill gets rid of the subsidies for those who cannot afford the insurance they are obligated by law to obtain.
These are the three provisions that were essential to the ACA and none of them can be sustained without the others. Everyone — including (at least rhetorically) President Trump — seems to like the idea of protecting people with pre-existing conditions (people who, before Obamacare, had long been driven out of the insurance market), but without the individual mandate, premiums will soar; without the subsidies, some people couldn’t comply with the mandate, hence undermining the entire effort.
So the GOP bill certainly kills Obamacare. But it also replaces it with essentially nothing adequate for those with preexisting conditions if states do, in fact, opt out. An independent analysis conducted by Avalere Health — and I cannot speak to the veracity of this analysis — suggests that the GOP replacement would cover only about 110,000 Americans — just 5 percent of those currently enrolled with a chronic condition. As a side note, The GOP bill explicitly allows insurance companies to charge up to five times higher premiums for those over 65, whereas Obamacare held the line at three times — one reason the AARP opposes it. So, yes, people with pre-existing conditions will quite predictably be dropped over time.
Just as egregiously, the bill also drops the Medicaid expansion provisions of the ACA and dramatically reduces funding to Medicaid ($800 billion over 10 years) making it much more difficult for states to subsidize health care for the poor. The Congressional Budget Office estimates that 14 million people will be dropped from Medicaid over the next ten years, not because they suddenly enter the ranks of the middle class, but because they won’t qualify under the more stringent requirements demanded by the evaporation of funding (particularly in states Trump won, which will be less likely or able than more liberal states to fill the gaps in federal funding). So it’s back to the ER (at best) for those folks (one reason the hospital industry — the American Hospital Association — also opposes the bill. Note the accumulating list of those opposed. I haven’t mentioned the American Medical Association, American Nurses Association, or the American Academy of Pediatrics).
The CBO analysis of this bill estimates that 23 million people would lose health coverage as a result. It looks like a bill designed not to fix anything but to undermine the effort the ACA made to ameliorate some of the most egregious flaws in our healthcare system by covering the poor and sick (poor and otherwise) with some increases in taxes on the wealthy (the Obamacare subsidies were funded by increases in Medicare payroll taxes on those making over $250,000 per year). The new GOP bill, by contrast, gives a tax cut to the wealthy and consigns 23 million more Americans to a health-insurance-less future — which, by the way, is more people than Obamacare actually helped in the first place. Think about that for a minute.
I’ve heard it said that the difference between Democrats and Republicans on healthcare is that liberals care about whether people actually have access to good affordable health care and Republicans care about the cost. But that is too simple. If Republicans cared about the cost they wouldn’t offset the dramatic cuts to health care with a tax cut.
But the real issue is a moral one, and a question of national character: What kind of a nation we are going to be? What kind of people? House Speaker Paul Ryan says that the main problem with Obamacare is that “people who are healthy pay for people who are sick.” There is a moral dimension to the set of assumptions underlying this complaint that has significant long-term implications for our polity. The idea that those who are healthy now help pay the cost of those currently suffering is, in part, the point of the welfare state (the social safety net), and indeed of insurance itself (which is designed to spread the risk — and cost — of medical conditions across the entire population, medical conditions you might not have now and might not ever have, but, then again…). It’s the same reason we pay taxes for public education for our children: me for your children as well as mine (even if mine have graduated or even if I had no children). Because we understand that a well-educated and healthy citizenry makes a better society for all of us and that these are in some fundamental sense, public obligations.
Essentially, it assumes a common good. To question that assumption, as I think Paul Ryan does consistently, is in some sense to question whether we are a nation at all.
Why did men and women from Alabama (and California and Michigan and Indiana?) sign up for military service when the World Trade Center was struck in 2001? What has Alabama to do with New York? I think the answer is that Alabamians recognized in that moment that America itself was under attack and they rightly joined in the common cause to defend the nation and its interests just as Americans have always done since the Revolution. Those citizens who joined recognized implicitly that our shared experiences in history have made us one people, that the well-being of Alabamians is bound up with that of New Yorkers because we share a common heritage and set of institutions, values and traditions. The flourishing of the well and well-fed is likewise ultimately bound up with our eagerness to help our sick and needy fellow citizens flourish also.
The rhetoric and rationale of the GOP bill, by contrast, throws millions of our fellow citizens (and, in its ultimate logic, all of us) back, as Hannah Arendt put it, “on their natural givenness, on their mere differentiation” and undermines “that tremendous equalizing of differences which comes from being citizens of some commonwealth.” Americans have traditionally worked and paid and fought and strived together for the common good, for a better society, whether this means defending against military threat or educating our children, or exploring space, or eradicating poverty in Appalachia, or building highways, and conserving our environment, or responding to natural disasters, or finding cures for diseases.
We can — and ought to — argue about what policy options will best achieve it, about the relative role of the federal government versus the states, about the relative role of public versus private investment. That’s politics; we deliberate over how to get there, and compromise some of our preferences along the way in that effort. We assume the integrity (honestly arrived at) of the alternative set of preferences. But to call this assumption into question — that there is a common good over which we deliberate and compromise — calls into question the meaning of the nation itself.
I think people are right to be troubled by this ill-considered bill (passed in the dark without public hearings or exposure of its flaws). I don’t think questions about it and challenges to it are easily dismissed prima facie as “lies” from “the Left.” Health insurance is really complicated. There are difficult trade-offs with any proposal. Obamacare is by no means perfect (as most Democrats would admit). I’d be excited to see some adjustments, fixes, to make it work better, more efficiently for everyone. But is this new GOP bill an actual solution or even an honest effort to fix the flaws or relieve the burden from American citizens who are suffering and afraid?
Despite what Paul Ryan says, I think the answer is obvious if you ignore the words and follow the money, so to speak. I don’t think any of us, left, right, or center, should be enthusiastic about a bill so transparently designed to indulge the rich and augment the power of the powerful, even if that means people will suffer and die as a consequence. “The wicked draw the sword and bend their bows, to bring down the poor and needy,” writes the Psalmist. I think we can do a lot better as a country than that. We must if we are to remain a country. Let’s work together to make it great.
Brian Steele is an associate professor of history at UAB, specializing in the American Revolution and the early republic. His first book, Thomas Jefferson and American Nationhood (Cambridge, 2012) was a finalist for the George Washington Book Prize and is now out in paperback.