Promises, Promises: Lessons for Selling TrumpCare
By Richard Sorian
Having finally rolled out their legislative proposal to repeal and replace the Affordable Care Act, President Trump and the Republican leaders in Congress are scrambling to corral enough support to get the American Health Care Act (AHCA) through both houses of Congress with little or no Democratic support. Needing every vote they can get, the GOP leaders are making promises they can't keep. For example: Health and Human Services Secretary Tom Price told Meet the Press that "nobody will be worse off" under the new legislation. House Speaker Paul Ryan has promised American families will have "lower costs, more choices and greater control." And the most popular pledge, repeated by dozens of GOP members of Congress: "We won’t pull the rug out from under anyone.”
When then-President Barack Obama was selling the Affordable Care Act to the American public in 2010, he promised: “if you like your healthcare plan you can keep it.” But his advisors knew that statement would come back to bite them. While it helped push the ACA through it would later be used as a cudgel against Obama and his fellow Democrats in a series of disastrous election cycles. In 2013, PolitiFact cited Obama’s promise as the “Lie of the Year.”
Obama’s staff knew that the law would require millions of Americans to give up their existing insurance plans and choose another that had richer benefits and higher premiums but let him make that promise repeatedly. Their justification: Those existing plans were too skimpy and didn’t provide people with the protection they need. They even tried that age-old DC spin of saying “what the President meant was…..” All true but far from convincing.
Why rehash such old news? Well, the new Republican majority in Congress and President Trump are walking dangerously close to that same line between truth and fiction. When they say they “won’t pull the rug out from under anyone,” the public and the media hear a promise that people who like being insured will keep being insured after the enactment of the new plan. The problem for the Republicans is the same one the Democrats faced in 2010 – that’s almost certainly untrue.
Most analyses of the Affordable Care Act find that between 20 million and 23 million Americans gained health coverage thanks to the law. A little more than half got covered by expanded Medicaid eligibility adopted in 31 states and the District of Columbia and paid for with federal dollars. The rest bought coverage on the Health Insurance Marketplace (a.k.a., HealthCare.gov) using subsidies provided by the federal government. As a result, according to the Kaiser Family Foundation, the percentage of Americans without health insurance dropped from 20.4% in 2013 to 12.8% in 2015, representing a 7.6 percentage point drop, or a 37% decline. The biggest declines occurred among Latinos and African Americans and in southern states.
The new GOP plan would phase out the extra Medicaid dollars and put a cap on the federal share of funding for that program going forward. The Obamacare subsidies – keyed to a percentage of the premiums charged in each region of the country – would be replaced with flat tax credits that top out at $4000.
While official estimates aren’t in yet, most analysts are predicting enactment of the AHCA will result in millions of Americans losing the coverage they got under the ACA. Estimates range as high as 15 million or more. Most of Washington is waiting for the official word from the Congressional Budget Office, which is analyzing the GOP plan as we speak. If the CBO estimates match the predictions of millions losing coverage the job of passing the AHCA – already a tough slog – becomes much more difficult.* The small but influential group of Republican moderates in Congress will balk at the notion of their constituents losing insurance. The larger but more poorly organized group of ultra-conservatives are already unhappy that the bill keeps some key parts of the ACA in place and will jump ship if efforts are made to make it more generous. This puts Trump, Ryan and Senate Majority Leader Mitch McConnell in a box with few ways out.
If the GOP succeeds in passing the AHCA, most of the pain is delayed until 2020 but it might well begin to be felt in 2018 during the next Congressional elections. If past is prologue, Republicans could lose enough seats to hand the Senate back to Democrats and sharply reduce the GOP majority in the House.
*Update: The CBO released its estimates of the impact of the AHCA March 13th and found it would lead to 14 million Americans losing insurance coverage in 2018 and 24 million in total in 10 years.
Richard Sorian is a veteran observer of U.S. healthcare policy. The views in this post are his own.