Over the past two years, Donald Trump has made clear, repeated promises to protect health insurance for those who have it and to expand it to those who don’t. “I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid,” he said in May 2015 shortly before entering the race for the White House. Fast-forward to the presidential transition, and he made a similar promise in an interview with the Washington Post, pledging a health care plan that would feature “insurance for everybody” with “much lower deductibles” and help for those who can’t afford care on the private market: “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
Except now that the time has come for an actual plan, it is happening. The Congressional Budget Office’s “score” of the American Health Care Act isn’t infallible, but its analysis is in line with other estimates. That analysis shows that Trumpcare will slash coverage for millions of Americans and force millions more to choose between basic necessities: health care or rent, medicine or food. What Americans get in return is a massive tax cut, to the tune of $600 billion, with the wealthiest 0.1 percent of taxpayers seeing the most dramatic benefits.
No politician who wants to stay in office would defend this bill on its merits. Which means its advocates—well-aware of its dire outcomes for low- and moderate-income people—have to obfuscate. On Tuesday, Mick Mulvaney, director of the Office of Management and Budget, took a different approach, blasting the CBO as inaccurate. “I don’t believe the facts are correct,” Mulvaney said on MSNBC’s Morning Joe. “I’m not just saying that because it looks bad for my political position. I’m say that based upon a track record of the CBO being wrong before and we believe the CBO is wrong now.” (An analysis of CBO forecasts on the Affordable Care Act found that they were “reasonably accurate.” The CBO is itself a nonpartisan office.)
Mulvaney’ choice to dispute the math pales in comparison with House Speaker Paul Ryan’s approach: deny that the report says what it says. “This report confirms that the American Health Care Act will lower premiums and improve access to quality, affordable care,” said Ryan in a statement released on Monday. “CBO also finds that this legislation will provide massive tax relief, dramatically reduce the deficit, and make the most fundamental entitlement reform in more than a generation.” His colleague, House Majority Leader Kevin McCarthy, took a similar tack. “This report by the CBO confirms that this first phase of health reform, the American Health Care Act, uses conservative and free-market principles that will empower Americans with access, choice, and affordability.”
Spin is part of politics, but this goes beyond a simple slant or an overly rosy picture. To say that the CBO report shows that the AHCA will “improve access” or “empower Americans” is to brutalize the English language.
Under the plan as written, 14 million people would lose their insurance by 2017, and the total number of uninsured would grow by 24 million over 10 years, for a total of 52 million in 2026 (compared with just 28 million people under current law). The reasons are simple: The bill cuts hundreds of billions from Medicaid—the joint state-federal program that insures low-income Americans—and shrinks subsidies for health insurance on the private market.
Worse, the CBO estimates that premiums under the AHCA would rise by 15 to 20 percent in the first few years, with an overall decrease beginning in 2020 driven by a new policy regime, where insurers are free to charge older Americans up to five times more than their younger counterparts. My Slate colleague Jordan Weissmann offered details:
With Obamacare, a 64-year-old earning $26,500 per year in 2026—175 percent of the poverty line—would have to pay $1,700 for insurance, after tax credits. That plan would cover 87 percent of their medical costs, on average. Under the AHCA, or Trumpcare, that same person would owe a full $14,600 after tax credits for a plan that only covers 65 percent of their medical costs.
Premiums will go down, in other words, because financial pressure will force older people to leave the market and forgo health insurance.
Instead of defending the bill on its merits, Ryan and Republican leaders have taken to vaguely proclaiming that it is offering “freedom” and “choice” to consumers. Perhaps, in a world where insurance companies are free to offer plans without mandated coverage areas, those older people will have greater “choice” and “freedom.” But only if those words are empty of any real meaning. One can’t reduce freedom to choice when those choices are bounded and circumscribed by income. A family that can’t afford health insurance hasn’t “chosen” to go without it; a person who lacks options for decent housing isn’t exercising his “freedom” when he is forced into a slum. Given what we know about the Republican health care bill, Ryan and McCarthy’s invocation of “access” is akin to praising the market for giving the wage laborer access to an expensive car or a mansion. For Republicans, basic access to health care will become another luxury good. Except not having an Audi or seaside estate won’t kill you, while not having insurance might.
Unfortunately, there’s only more nonsense to come. The American Health Care Act is more than a bill; it represents the sum of Paul Ryan’s ideological aspirations, his career-long effort to dismantle core guarantees of the social safety net, to build a society where economic security becomes a privilege of the wealthy, risk and uncertainty the lot of everyone else. Ryan, in other words, won’t abandon his bill. Not as industry groups line up against it, not as Senate Republicans begin to balk, not as some on the right begin to voice their skepticism or even hostility.
Instead, in addition to President Trump and his broken promises, we’ll have to live with another voice of dishonesty: Paul Ryan, insisting that we trust him, and not our lying eyes.