Last Thursday, Senate Republicans unveiled the Better Care Reconciliation Act, their version of the American Health Care Act. Senate Majority Leader Mitch McConnell, who has shepherded the legislation, says it repeals Obamacare and replaces it with something better, fulfilling the party’s promises of the past seven years. “Obamacare is a direct attack on the middle class, and American families deserve better than its failing status quo—they deserve better care. That’s just what we’re going to continue working to bring them,” said McConnell in a statement unveiling the proposal. But that’s just rhetoric. In truth, Republicans left the foundation of the Affordable Care Act intact, slashing benefits, scrapping regulations, and heightening penalties but still preserving the basic public-private structure of the law.
The most significant change is to Medicaid, the joint state-federal health care program that finances coverage for more than 70 million Americans. On top of ending the Medicaid expansion offered to states by the ACA, Republicans would cap Medicaid spending and allow states to make drastic changes to coverage and eligibility, reducing the value of the program. It cuts Medicaid by hundreds of billions of dollars in its first 10-year window and makes even deeper cuts after that, endangering coverage and care for millions of Americans, including families who need Medicaid to afford care for elderly or disabled relatives.
With their plan, Republicans will end Medicaid as it exists and use the savings to fund tax cuts for the richest Americans. This isn’t popular. But rather than power through this unpopularity and make an honest case for the law, Republicans and their White House allies have decided to just lie.
That was the spectacle on Sunday morning when Republican advocates didn’t defend the plan as much as they lied about its contents. On CBS’ Face the Nation (where I contribute analysis), for example, host John Dickerson pressed Sen. Pat Toomey of Pennsylvania—one of 13 architects of the proposal—on those Medicaid cuts. “The Senate bill will codify and make permanent the Medicaid expansion,” replied Toomey. “And, in fact, we will have the federal government pay the lion’s share of the cost. ... No one loses coverage.”
Only the thinnest bit of legalese keeps this statement from being an out-and-out lie. It is true the Senate bill doesn’t formally end the expansion. What it does instead is reduce the overall Medicaid funding stream. Under current law, the federal government pays the full cost of the Medicaid expansion until 2020, at which point it winds down to 90 percent of the cost. The Republican plan would bring that percentage down to the normal matching rate for Medicaid: 57 percent on average. This is a cut, and it’s not hard to see what happens next. Eight states have laws that automatically end the Medicaid expansion if the federal government reneges on its original 90 percent match, reducing coverage by an estimated 3.3 million people. Other expansion states will have to choose between raising taxes to meet the strain on their budgets or ending the expansion program altogether.
On top of this, the Republican plan replaces the open-ended match—which benefits poorer states with larger Medicaid populations—with a per-capita cap linked to medical inflation for the first eight years and then the overall Consumer Price Index. What this means, in plain terms, is that states get a set amount of money per person to pay for Medicaid costs. That amount grows in pace with a narrow inflation measure and then a wider one. The problem for states and beneficiaries is that Medicaid grows faster than both measures. What looks like a wonky technical change is, in reality, a substantial cut to the program. When coupled with rules that allow work standards and other strict requirements for eligibility, Republicans have given states both a reason and means to reduce coverage and shrink services.
Sen. Toomey, in short, is playing word games. He and his colleagues have ended the Medicaid expansion—they just don’t have the courage to make that plain.
To Toomey’s credit, he at least spoke within the bounds of reality. White House Counselor Kellyanne Conway, in speaking to George Stephanopoulos on ABC’s This Week, gave an Orwellian performance, denying outright what our eyes can see. “These are not cuts to Medicaid,” said Conway. “This slows the rate for the future and it allows governors more flexibility with Medicaid dollars because they’re closest to the people in need.” To which Stephanopoulos replied, “I don’t see how you can say the more than $800 billion in savings is not cuts.”
Conway also promised that the Republican bill would lower premiums, echoing a similar claim from Health and Human Services Secretary Tom Price. “The plan in its entirety will absolutely bring premiums down, because you increase competition, you increase choices for individuals,” he said in an interview with Dana Bash on CNN’s State of the Union.
This isn’t true, either. In its analysis of the Republican plan, the Kaiser Family Foundation finds huge premium increases for older consumers and others with greater health needs. Under the Affordable Care Act, a 60-year-old worker making $50,000 in Maricopa County, Arizona, has a $5,100 premium if he or she purchases a middle-tier policy. Under the Republican plan, that premium quadruples to $20,450. Indeed, there’s almost no county in the country where that 60-year-old wouldn’t see a massive spike in costs, rendering all but the most junk insurance unaffordable.
These lies and half-truths are easily debunked. But they are effective because hardly anyone knows they are false. The Republican health care plan is still unpopular—in the latest Kaiser poll, just 30 percent of respondents say they have a positive view of the proposal—but only 38 percent know that it contains “major reductions” in Medicaid spending. Americans, who support Medicaid by an almost 4 to 1 margin, are largely unaware that Republicans would cut the program into something paltry and unrecognizable. What would that number look like if the party were honest about its plans? Or if its quasi-official organs, like Fox News, weren’t so eager to cheerlead the deception?
This gets to an even bigger lie—the one that got us here in the first place. As a candidate, Donald Trump campaigned against entitlement cuts: “Save Medicare, Medicaid, and Social Security without cuts, have to do it,” he said in his campaign announcement. Later, he used this as a cudgel against other Republicans. “I am going to save Medicare and Medicaid, Carson wants to abolish, and failing candidate Gov. John Kasich doesn’t have a clue,” he said. And during the general election, he slammed Hillary Clinton as an enemy of those programs, even as she promised expansions. “[Clinton] wants to knock the hell out of your Social Security, she wants to knock the hell out of your Medicare and Medicaid. And I’m going to save them, OK?”
With this rhetoric, Trump reassured those voters who supported his prejudiced rhetoric against racial and religious minorities but rejected traditional Republican posturing on reducing government services. He told them, quite literally, that he would take care of them, protecting their white identity as well as their health. But this was a bait and switch. “Trumpcare” would eviscerate the social safety net, leaving many of his voters to the mercies of a cruel market.
Would Trump have won his narrow Electoral College victory, and thus the White House, had he been clear about what he actually intended to do once in office? Would he be in a position to slash Medicaid had he not promised to protect it? A “no” answer poses hard questions for our democracy. Democratic governance depends on a level of honesty and transparency. Politicians who lie about their programs are politicians who make informed choices—and fair elections—impossible. What does one do when the chief elected official has no interest in the truth? How can representative government even work when honesty itself is fungible?