The greatest advantage the Republican Party held, through eight years of political war over the provision of health care, was not having a plan to defend. After November’s elections handed them full control of government, Republicans designed a strategy to retain that advantage: repeal-and-delay, which would have allowed them to eliminate Obamacare without specifying the replacement. Repeal-and-delay failed, forcing them instead to pass a replacement plan. That plan has proven wildly unpopular. Indeed, it is so deeply unpopular that Republicans have given up defending the plan at all. Instead, they are back to promising an unspecified, future plan that will be revealed only after Obamacare has been gutted first.
The most significant development to come out of the last week is that Republicans no longer defend the American Health Care Act. When confronted with the fact that his plan would make counties that supported him far worse off, Trump acknowledged, “Oh, I know.” Paul Ryan, appearing on Fox News Sunday, echoed Trump. “We do believe we need to add some additional assistance to people in those older cohorts,” he told Chris Wallace. “We believe we should have more assistance, and that’s what we are looking at.” Secretary of Health and Human Services Tom Price told CNN, “This is not the plan.”
By “this,” Price meant the plan that the White House and Republican leadership had claimed as its plan. The real plan has “three prongs,” of which the bill is only the first. The other two involve a combination of regulatory moves that may or may not be legal and a package of legislative changes that stands a zero-percent chance of being passed into law. (They’re omitted from this bill because they cannot be included in a reconciliation bill, and thus are subject to a filibuster and require Democratic support, which will not be forthcoming.)
Fixing the Republican plan is not a technical problem akin to rejiggering some wires in the shop. It means allocating real-world resources. The GOP plan makes coverage unaffordable for the old and poor because they’re expensive to cover, and Republicans don’t want to pay for it. They insist their plan repeal Obamacare’s taxes on the rich, reducing the amount of resources available for coverage. They also insist their plan expand “choice” and “freedom,” which in practice means having the choice and the freedom not to pay for other people’s medical care. But if you don’t make somebody pay for it — either forcing insurers to give them artificially low premiums, or by taxes, then it won’t be paid for.
The regulations Republicans tout, which would allow insurers to sell skimpy plans to healthy people, would exacerbate the problem. Healthy people would get cheaper plans that don’t cross-subsidize medical care needed by the old and sick. That would force the old and sick to bear even more of their costs. If there was a “real” Republican plan in writing, its effects would be even more gruesome. And so it must remain an abstraction.
One Republican member of Congress hilariously stated that he would vote for the plan on the basis of unspecified assurances from Trump to eliminate features that would punish older, poorer Americans. “The President listened to the fact that a 64-year-old person living near the poverty line was going to see their insurance premiums go up from $1700 to $14,600 per year,” said Alabama representative Robert Aderholt. “The President looked me in the eye and said, ‘These are my people and I will not let them down. We will fix this for them.’”
So, like every Republican alternative to Obamacare, this one has vaporized upon contact with the real world. The real Republican plan, once again, exists on an ethereal plane. Its features cannot be quantified but they can be described in generalities. Everybody who has seen it says it is, or will be, wonderful.