For the past seven years Republicans have promised to “repeal and replace” Obama’s premier healthcare law. All of their attempts had failed, and while the GOP had discussed what they wanted to change, they had never fleshed out the details of their replacement. In 2017, when Republicans finally had the presidency and both chambers of Congress, they made their first priority repealing the Affordable Care Act. After two months of drafting the what was became known as the American Health Care Act behind closed doors and rushing the proposal through committees, the Republicans failed.
The GOP’s first failure was that they lied about the impact of their replacement for the ACA. Republicans had promised to lower premiums and deductibles. President Trump himself as a candidate had famously said that he would insure everyone with insurance that was “great.” However, once the Trump Administration was underway and the new Republican dominated Congress was at work, it became clear to Americans that these promises would not be kept, the ACA’s popularity soared and many Americans began protesting Republicans’ determination to repeal the ACA.
Once Republicans revealed their proposal, the American Health Care Act, it was met with unique unpopularity from both sides of the aisle. The American Medical Association, the AARP, the Heritage Foundation and the Cato Institute all came out against it. No coalition backed the American Health Care Act apart from some Republicans in Congress towing the party line. This all raises the question what was this unpopular bill, and what exactly was it replacing?
In 2010, President Obama signed the Affordable Care Act, Obamacare, into law, attempting to increase the quality and affordability of healthcare in the US. The ACA created insurance exchanges that were subsidized at incomes up four times the poverty line, required insurance providers to accept all applicants regardless of sex or pre-existing condition, and created an individual mandate requiring people to have health insurance or pay a fine. The mandate was to ensure a diverse mix of young, healthy, unhealthy, and older clients in the insurance pools to keep premiums down. The ACA also allowed people to stay on their parents’ insurance until age 26 and created a list of “essential benefits” that insurance companies were required to cover. These essential benefits include outpatient care, emergency services, hospitalization, maternity care, mental health and substance abuse services, prescription drugs, rehabilitation services, and laboratory services. Lastly, the ACA expanded Medicaid from the poverty line to 138% of the poverty line. All in all the ACA did little to affect the quality of healthcare in the US, but decreased the number of uninsured by 20-24 million.
Paul Ryan’s proposal for a new healthcare law, the American Health Care Act, was revealed on March 6, 2017, only three weeks before the scheduled vote to repeal the ACA. Ryan’s bill tried to stop what Ryan believed were spiraling healthcare costs and to decrease federal spending on healthcare. The AHCA removed the individual mandate requiring people to get insurance and replaced it with a penalty when someone decides to get insurance after having a lapse in coverage. It stopped the medicaid expansion for anyone who tried to sign up after 2020 and ended the federal government’s subsidies of insurance, replacing them with more widely distributed tax credits. The result was that a 64 year old making $26,500 would go from paying premiums of $1,700 under the ACA to $14,600 under the AHCA, while a 21 year old making $68,200 would go from paying premiums of $5,100 under the ACA to $1,450 under the AHCA. The the old and poor would suffer, and in many cases be forced to go without healthcare, while the young and well-off would pay less under the Republican’s plan. This added onto the number of taxes that the plan cut as well, most of which benefitted the wealthy. After a negotiation with the Freedom Caucus, it was changed to also remove the “essential benefits” requirement mentioned earlier, no longer requiring services like prescription drugs and emergency services. It did, however, keep the pre-existing conditions clause, requiring people with pre-existing conditions to be eligible for healthcare, as well as continued to allow children and young adults to be on their parents insurance until 26.
However, the end result of all these changes meant that 23 million people would lose insurance within the next ten years and the old and poor would pay unsustainably higher costs for healthcare. The benefits of the plan: it would save the federal government a little over one hundred billion dollars in the next ten years, reduce costs for the young and well off, and reduce taxes primarily for the rich. Nationwide, the AHCA polled at an average net popularity of -22%.
Adding on to the un popular and in many ways harmfully thoughtless plan, was the factionalization of the Republican party that that ended up destroying the AHCA. While Paul Ryan and most middle-of-the-road Republicans supported the AHCA, many moderate and very conservative Republicans fought against it. Ten members of the moderate caucus feared that they would lose reelection because of the low approval ratings for the bill and the number of their constituents who would become uninsured. Fifteen hard-line Republicans, mainly members of the very conservative and ideological Freedom Caucus, felt that Ryan’s plan did not go far enough. These members felt it left too much of the ACA in place, dubbing it “Obamacare-lite.” Ryan and Trump found themselves unable to mediate a compromise with either side to gain enough votes to pass the AHCA through the house.
All of this raises huge questions about Republicans’ ability to push through large pieces of legislation. Tax reform is by no means an easier topic than healthcare. NPR White House correspondent Tamara Keith summed up the probability of Republicans’ being successful with tax reform, saying “If I told you that I couldn’t run a 5k today but I was going to do a marathon next weekend, you would have a right to be skeptical.”
