Ok look, now I know I may not be as smart as a member of Congress, either in the Senate or the House, but I seriously don’t understand why it is that the Republicans seem so determined to make this entire “repeal and replace” process regarding Obamacare so difficult. I saw Paul Ryan on Fox News last night and all he kept repeating, nearly ad nauseam, was how the Republicans are keeping their promise to “repeal and replace.” I can only assume that he thinks we’re all too stupid to recognize that what’s currently being offered is nothing more than smoke and mirrors. And I’ll tell you right now, if what we’re seeing now becomes a reality, then come 2018 Ryan will no longer be Speaker, McConnell will no longer be leading the Senate and the Republican Party will be returned to the status which they seem to be much better suited. Now either these guys think we’re bluffing or they simply don’t care, but either way the American people will have their say.
And so here we are, seven long years later, years spent listening to these same Republicans continue to make the same promise to “repeal and replace” Obamacare. And after years of waiting for them to come up with what we all hoped would be viable plan to do just that, what do we get? We get a bill from House Speaker Paul Ryan which, for all practical purposes, is even worse than Obamacare! Seriously? And when you stop to think about it, it’s a rather impressive feat because, in their pursuit of a lower score from the Congressional Budget Office (CBO), Democrats made Obamacare just about as bad as they thought they could get away with while still calling it “universal” health care. While many other analyses are focused on how Ryan’s American Health Care Act will make life worse for certain lower income Americans compared to Obamacare, pointing out the similarities is more important for understanding its politics.
Under Ryancare, most people will get coverage through their employer, just like with Obamacare. And in both cases, many of the poor will get coverage through Medicaid. And with both plans, lower/middle income people without employer coverage will be encouraged to use tax credits to help buy ‘regulated’ private insurance. Neither Obamacare nor Ryancare has any real price control measures to deal with our dramatically out-of-control healthcare prices. Both plans leave groups of Americans without insurance they consider to be ‘affordable’. Finally, both are heavily “financed” by a Cadillac tax on expensive employer-provided insurance that is delayed for a decade, resulting in no one expecting the tax to ever go into effect. There are four major areas where Ryancare does differ from Obamacare, but even here, most of Ryancare’s provisions are only a bad funhouse mirror version of very similar Obamacare policies. They are:
1) Medicaid: The most important difference is that Ryancare will change how the Medicaid expansion works and is funded starting in 2020 by freezing enrollment and creating a per capita cap, which places funding limits on each person. Of course, that might never happen. If the GOP doesn’t feel comfortable implementing these changes now, I don’t know how they think it will be easier in the middle of a presidential election. This Medicaid cut will cause about 4-6 million people to lose Medicaid coverage, according to S&P (which I need to cite since there is no CBO score).
2) Tax credits: The second most important difference is that Ryancare will, in 2020, replace Obamacare’s age/regional based, means-tested, refundable tax credits to buy private insurance with age-based, sort-of-means-tested, refundable tax credits to buy private insurance. On the plus side, the more modest means-testing design in Ryancare means the tax credits should be slightly easier for the government to administer, will make insurance more affordable for some Americans who currently make too much to qualify for Obamacare credits, and somewhat addresses the issue that means-testing created a big effective marginal tax on lower income people. The issue is that Ryancare’s “fixes” the problem created by Obamacare only providing lower income Americans enough tax credits to make insurance affordable by basically making tax credits equally insufficient for everyone. And since they aren’t pegged to the cost of health care, the Ryancare tax credits could become less sufficient every year.
3) Individual mandate replaced by late enrollment penalty: Ryancare gets rid of the deeply unpopular individual mandate. In its place, it imposes a late enrollment penalty that’s supposed to nudge people to buy private insurance in a timely manner. If you fail to buy coverage for awhile, you will need to pay 30 percent more when you do buy insurance. Both systems suffer from the basic flaw that they don’t make insurance truly affordable for everyone but punish you if for some reason you feel you can’t make your premiums. Obamacare has hardship exemptions for the mandate, though.
4) Taxes repealed: Finally, Ryancare repeals almost all of the other Obamacare taxes, meaning it probably won’t pay for itself. Repealing the Obamacare taxes on the rich will likely be viewed by many as being nothing more than just a big giveaway to the rich.
Ryancare is not a change of structure from Obamacare. It’s a change of scope. The big similarities, and the fact that even the differences are more a matter of size than radical policy redesign, completely undermines the GOP’s ideological and political position. It’s not based around a coherent theory for what is wrong with health care, nor does it offer any big new ideas to fix our problems. By comparison, there are intellectual theories behind how plans like the old Wyden-Bennett bill or Medicare-for-All could improve conditions with big system-wide changes. There is no principle or story behind Ryancare to explain how, even in theory, it could make things better. There is no reason to even hope it could make things cheaper or coverage better. There is no way to look at what is really nothing other than a worse version of Obamacare and not conclude that it would have an impact similar to Obamacare.
So now Republicans are left trying to explain why they kept claiming Obamacare was such a terrible existential threat that it can be completely fixed by cutting rich people’s taxes and making it less generous to some people in need. As a result, the ideological Republicans aren’t happy, the more pragmatic Republicans who would need to implement it aren’t happy, the non-partisan groups aren’t happy, and even the political hacks don’t know how to sell it. The Republican PR team is honestly left pointing to the fact that Ryancare has fewer pages as being proof that it’s better. Selling Obamacare was almost impossible for Democrats; selling what is really nothing more than an even worse version of Obamacare should prove even more difficult for the Republicans. Frankly, I don’t understand why it is that the Republicans seem so determined to make things so much more difficult than they need to be. A lot more difficult!
And I’ll tell ya something else, the Republicans are going to have one chance, just one, to get this thing right, and while Ryan may think he’s being pretty clever, the truth is, he’s not fooling anybody. Personally, I think Ryan, like most politicians, is pretty lazy, hence is recent and lame justification regarding the eight day work schedule planned for the House next month. And while Ryan may think he’s pretty cute, I think most folks realize that he’s doing little more than trying to appease his big donors in such a way that will allow him to claim he tried his best to keep things as close as possible to the original Obamacare. At least he can say, "See I tried to keep it as the establishment wants, but that's just not going to fly". His big donors can't say he didn't try. I think Ryan has known all along that this rendition was never going to pass the smell test. So now let’s move forward with a serious attempt to “repeal and replace” and leave this attempt behind.
If the GOP insists upon pushing millions of poorer Republican voters, who rely on Medicaid so they can get medical treatment and survive, off of Medicaid, the GOP will surely lose its present majority position in government and the mantra of “Make America Great Again” will be relegated to bumpersticker status in much the same way that “Hope and Change” was. It's called cutting off your nose to spite your face, I think. Alternatively, we can replace Obamacare and move on to accomplish a hundred other important tasks that need to occur in order for “Make America Great Again” to become a reality. The stars will never again align like this in our lifetime. If Republicans blow this opportunity the “Make America Great Again” is dead and the Democrats, like the Phoenix, will rise again. And America will go into steep socio-economic and moral decline while the borders are thrown wide open and our civilization declines.
Those who now seem to be so determined in their effort to shove through what is nothing more than a soup sandwich do so not only at their own political peril, but it also places at risk the future of our country. Because their continuing opposition to this new Americanism will most assuredly destroy this country just as quickly as the regressive left in this country will. Republicans need to focus on getting the job done, and done right, while keeping the promises that were made so that we can then move on to trade, taxation, immigration, and a hundred other things that are now, after eight years of Barry “Almighty”, in urgent need of being addressed! Come on people, it’s just not that freaking complicated. And if a simple old soul like myself is able to recognize that fact then why is it that those in positions of power seem to be so freaking mystified by the entire concept of doing what it is that they promised and in the way that they promised to do it!