I would venture to guess that congressmen Paul Ryan and Joe Kennedy don't agree on too much, but one thing they do appear to agree on is that the ineptly named American Health Care Act (aka Trumpcare) is first and foremost a bill about cutting taxes. Ryan trumpeted the bill as a $1 trillion tax cut and seemed entirely unfazed by the fact that the beneficiaries of the tax break were overwhelmingly the richest households and big drug and insurance corporations. Meanwhile, Rep. Kennedy denounced the bill as "a tax cut wrapped up as health care" and called it "an act of malice rather than mercy" in a statement that went viral on YouTube.
And the Congressional Budget Office (CBO) has made it crystal clear who would pay for that tax cut: working families and especially older adults and people with disabilities. CBO projects that should AHCA become law, 24 million people would lose their health insurance – that's 80 percent of the number projected to lose coverage with a full repeal of the ACA. The financial assistance that makes coverage affordable for people who lack employer-sponsored insurance would be cut almost in half and would be restructured in a way that provides more assistance for the middle class but dramatically scales back help for people with more modest incomes.
Promises Made, Promises Broken
Ironically, the biggest losers under Trumpcare are the voters who provided President Trump with critical support during the election. For example, A 60-year-old person with an income of $30,000 would see her or his assistance shrink by an average of $6,000 per year. Many Trump supporters are now nervous that their coverage will be taken away, but in the face of all evidence to the contrary, some still cling to the hope that their candidate will not abandon them. (Adding insult to injury for older adults, Trumpcare undermines Medicare's financial stability, despite Trump’s repeated promises not to cut the program. And the President’s budget called for eliminating federal funding for the meals on wheels program, among many other domestic program cuts.)
However, the greatest damage of Trumpcare may not be to the non-group insurance market, but to the Medicaid program. Notwithstanding his campaign promises, the legislation that Trump is backing "1,000 percent" would cut $880 billion in federal support for Medicaid. Cutting Medicaid would apparently fulfill a dream Paul Ryan has had ever since he was attending college keg parties… But the consequences for children and families, people with disabilities and seniors, should his dream become a reality, are serious. Capped funding would put states in a financial straightjacket, making it harder for them to meet the growing need for long-term services and supports or to respond to a disease outbreak like Zika or address the opioid addiction epidemic. Trumpcare would also force most states to abandon the recent expansion of Medicaid to more low-income adults.
Things Will Get Worse Before They Get Better
Not satisfied with inflicting all of these coverage losses, the most conservative members of the House are trying to make the bill even worse, and seem to be succeeding, at least for now. As the bill made its way through the Budget Committee, the committee took non-binding votes in favor of a more rapid phase-out of Medicaid funding for the 31 states that expanded the program under the ACA, making eligibility for non-disabled adults contingent on work and giving states more power to eliminate benefits or services for Medicaid beneficiaries. It is likely that some or all of these ideas will get converted into amendments in the House Rules committee where the bill is heading later this week before it goes to the floor.
While House leaders are trying to project confidence, the fate of the legislation in the House (let alone the Senate) is still unclear. Many of the most far-right members of the Republican House are still not on board. At the same time, changes meant to appease them could force some of the party's more moderate members – especially those in districts carried by Hillary Clinton – to think twice before voting to support a bill that would increase costs and cut coverage for thousands of their constituents. Many are unhappy with being asked to take a tough vote for a bill that could die or get substantially reworked in the Senate, and some have come out in opposition. Speaker Ryan is trying to keep these members on board by providing some additional help to older adults, but whether this will be enough to secure passage for the legislation in the face of opposition from health care providers, governors and concerned constituents remains to be seen.