The expanded health-care coverage created by the Affordable Care Act has been in place for just three years, and already its effects are measurable. Hospital-acquired conditions have dropped by 21 percent, saving more than 125,000 lives, in response to better incentives. (Before Obamacare, if hospitals had lots of infections, affected patients would return for more treatment, increasing hospital revenue.) Diagnoses of certain chronic conditions among low-income patients have risen. Access to routine checkups has increased, and people are now in less danger of falling into debt because of illness. Medical inflation has dropped to its lowest level in decades.
As Donald Trump’s Republican-controlled government assumes power, it has made its first task the dismantling of the law that has produced these gains. If we were watching a developing country consciously set about reversing its own social progress — shutting down its electrical grid, tearing out its indoor-plumbing system to revert to well water — we would find it baffling. The extent of the damage Republicans inflict remains to be seen, but one way to calculate it, should the dismantling occur, will be in American lives lost. The Congressional Budget Office has estimated that 18 million Americans would immediately lose their insurance, a number that would increase to 32 million by 2026. A study of mortality rates in Massachusetts before and after that state enacted reforms similar to Obamacare found that one life was saved for every 830 adults who gained insurance coverage. Eighteen million divided by 830 equals almost 22,000 lives at stake, plus untold suffering from millions who would be denied access to regular medical care. The fact that Republicans are embarking on such a cruel, self-destructive project at all speaks to the pathology that has engulfed the new governing party.
Trump has insisted throughout the campaign that he will “take care of everybody,” that his plan would be “much less expensive and much better” and is “very much formulated down to the final strokes. We haven’t put it in quite yet, but we’re going to be doing it soon.” This boast created some initial confusion within party ranks; Republican health-care adviser Yuval Levin reported that “the conservative health-care universe, including some people on Trump’s own team, quickly concluded that the separate administration plan he described was entirely a figment of Trump’s imagination.” Trump is employing the same technique he used to enthrall conservatives about the birther conspiracy, only in reverse: Rather than pretending that a real document (Barack Obama’s birth certificate) was fake, he insisted an imaginary document (the much cheaper, much better Trumpcare plan) was real. He is hardly alone in this. Trump’s lie was merely a less careful version of the same fantasy that Republicans have repeated for eight years. Since the health-care debate began in 2009, they have been promising that if Democrats scrapped their plan, Republicans could provide cheaper, better coverage to the uninsured. Indeed, even as far back as 1994, Republicans promised that if the Clinton health-care plan was defeated, they would start over and pass something terrific instead. They never did. If Obamacare had been defeated in 2010, health-care reform would rank as high on Trump’s agenda today as it did on George W. Bush’s from 2001 to 2008: last. Instead, Republicans are caught having to follow through on their impossible promises. The GOP health-care plan is the teenage nerd’s mythical girlfriend who lives in Canada — the one nobody has ever seen.
Republicans do have ideas on health care. The catch is that those ideas are resoundingly unpopular. They want to force Americans to make do with much cheaper plans that cover much less care. The party has refused to grapple with any of the trade-offs inherent in the issue. Two-thirds of all health spending is consumed by 10 percent of the public. The only way to cover the cost of their care is to make other people pay for it. Republicans denounce any such mechanism. They also denounce Obamacare’s regulations, proposing instead to let anybody buy the kind of insurance they want. But all those regulations serve the purpose of spreading the costs from the sick to the healthy. If healthy people can buy cheaper insurance that doesn’t cover expensive treatments they don’t need, then the cost of those treatments will be borne entirely by people with expensive medical needs. You could fund those treatments through taxes instead — but, of course, Republicans hate taxes even more than they hate regulations.
At his confirmation hearing, Tom Price, Trump’s nominee to run the Department of Health and Human Services, promised, “Our goal would be to go from what we see as a Democrat health-care system to an American health-care system.” He bashed Obamacare for its high deductibles, just as House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell have done repeatedly. But Price’s own plan would feature much higher deductibles than Obamacare, as would most Republican proposals. Price has previously written a plan that would give people a tax credit ranging from $1,200 to $3,000 a year. That’s only enough to pay for about one-third of the cost of an inexpensive individual plan on the market today. He would also let insurers charge higher rates to people with preexisting conditions, unless they manage the difficult task of maintaining continuous coverage. As an article in the New England Journal of Medicine explained, Price’s plan would be “likely to lead low-income and even middle-class healthy people to forgo seeking coverage until a serious health problem develops.” There are alternative Republican plans floating around that provide more-generous coverage, but the catch, as the Washington Post reported, is that “nobody seems to know how to pay for” it.
No wonder Republicans have carefully sequenced their legislative strategy in order to prevent any direct comparison between their ideas and Obamacare. If they believed Trumpcare might compare favorably with Obamacare, they would simply put it to a vote. Instead, their plan calls for separate votes — first to repeal Obamacare and then, in a later vote, to replace it with something terrific. Their only hope of success lies in first destroying the status quo and then using the threat of the disaster they created to somehow put pressure on Democrats, or even recalcitrant Republicans, to vote to put something, anything, in its place.
The party has taken its fastidious secrecy about its health-care intentions to absurd lengths. “In the lead-up to his confirmation hearings, Price has been kept out of the Trump transition team’s efforts to craft an Obamacare replacement plan,” CNN reported. “According to a senior transition official, the incoming administration wants Price to be inoculated from questions about what Trump’s alternative to the Affordable Care Act looks like.” Trump’s advisers would rather delay the process of devising their own plan than risk exposing their ideas to the public.
Republicans certainly aren’t pursuing their repeal-and-delay plan because it’s popular. Various polls have found that 20 percent of the public favors a repeal vote that doesn’t include a replacement plan. They are doing so because, now that they enjoy almost total control of the federal government, they are stuck. Republicans have been catastrophically successful at convincing their supporters that Obamacare is pure evil, devoid of any virtues whatsoever, and thus that it can easily be replaced with an alternative that is superior in every dimension. How far they will go to maintain their lie is a question on which millions of lives now depend.
*This article appears in the January 23, 2017, issue of New York Magazine.