The Republican party’s dream of an Obamacare replacement might yet become reality. But the House-passed American Health Care Act is a nightmare: a labyrinth of policy trade-offs and academic ideas the public has resisted entering. It’s currently polling in the 30s—a relative achievement, given that an earlier survey showed 17 percent support for the original legislation. Why all the low regard? Bedeviling the details. As the Washington Post’s Dave Weigel observed during a town hall for constituents of Rep. Tom MacArthur, who authored a key AHCA amendment that led to the bill’s passage, “Hearing MacArthur describe all this really hits home how difficult it is to beat something simple (single payer) with a pile of wonkiness.”
The GOP itself is much to blame. It rushed a complicated plan to a vote even though disunity abounded in its conference. Vice President Mike Pence said in January the majority’s goal was to replace the health care law in an “orderly” manner. That necessitates members falling in line, not out of it, as unsatisfied conservatives and uneasy moderates did before House speaker Paul Ryan pulled the legislation two months ago. But those same individuals have been fighting misperceptions about the bill. A prime example accompanied the release of a Congressional Budget Office estimate in mid-March. The CBO projected there would be 28 million uninsured Americans in 2026 under Obamacare, compared with 52 million if the AHCA were enacted. The higher estimate was largely based on people opting not to purchase coverage and a medium-term reduction in Medicaid spending. But Democratic lawmakers and commentators warped these forecasts to mean 24 million would people “lose” insurance thanks to Republican legislation. A credulous media adopted the talking point. By late-March, Americans opposed the bill 3-to-1.
There have been similar instances of politicians and the press poorly distinguishing what the legislation does and does not do. MacArthur’s amendment is the most significant one. It would allow states to conditionally waive some Obamacare mandates on insurers: One of them prohibits medical underwriting, or using health status in calculating premiums. Removing this restriction would allow insurers in waiver states to hike costs on certain consumers with pre-existing conditions. Critics seized on this to say the bill “undermines” the relevant consumers or “guts” their protections, ignoring that AHCA includes a potpourri of funds—as high as $108 billion available at various times over nine years—to help subsidize those higher-priced folks in “risk pools.”
Republicans could have helped themselves by explaining just how few individuals the amendment would affect. The American Enterprise Institute’s James Capretta uses an example of a 45-year-old cancer survivor on the individual market who has maintained his insurance coverage. “What’s happened is that Republicans actually have a plan to allow that person to stay in the regular insurance pool with everyone else, but they’ve been emphasizing pulling them out [into risk pools]. Because there’s some people in the party that think it would be better to pull them out,” Capretta told me by phone. “And so they’ve gotten themselves all bollocksed up politically, instead of selling to the guy who’s 45 in that circumstance and saying, ‘Don’t worry, as long as you stay continuously enrolled in insurance, you’re not going to be pulled out. You’re going to be treated like everybody else.'”
The complexity of the pre-existing conditions matter has allowed even more spurious notions to take root in the media and among activists. One is that “rape and domestic violence could be pre-existing conditions” under the AHCA, as a CNN story put it. A Washington Post fact check gave the claim four Pinocchios. At least 45 states already prohibit such discrimination. And it would require “several leaps of imagination” for this repugnant categorization to be permitted in one of the leftover states, the Post explains.
Further, the legislation pertains to only a small fraction of the population. Of the 244 million people under the age of 65 who were insured last year, all but 22 million were in group plans, such as employer-provided insurance. This 9-percent slice of the insured population is central to the issue of coverage affordability. And yet a Politico poll last week found that 42 percent of registered voters believed the legislation would jack their insurance costs. The AHCA may directly cause the recalibration of some premiums—but not even close to that many.
Who knows how much each of these aspects of the GOP bill weigh on individuals’ minds. But considered as a whole, they give a broadly negative impression of convoluted legislation. Perhaps the AHCA lacks merit in several respects. To make such an evaluation, however, the details need to come to the fore. As Rep. Dave Brat, a Virginia Republican and former economics professor, lamented: “Politics is dominating policy.”
