Washington snickered when President Donald Trump marveled that “nobody knew health care could be so complicated,” because everyone in Washington knew that. Wednesday’s long-awaited Congressional Budget Office review of the Republican health-care bill is just the latest reminder that it is, as Trump said, “an unbelievably complex subject,” full of subtleties and intricacies about medical underwriting and community ratings. It can get wonky, jargony and downright impenetrable.
But not everything about health care is complicated, and the bottom line of the CBO review is brutally straightforward. It turns out that when the government spends more on health care, more people get health care. The CBO concluded that the GOP bill would spend about $1 trillion less on health care, so about 23 million fewer Americans would have coverage. And most of the money stripped out of the health-care system would be returned to wealthy Americans in the form of tax cuts.
The complex details do matter, of course. The CBO found that the latest version of the American Health Care Act, which House Republicans passed earlier this month, would be slightly cheaper for healthy people and considerably costlier for sick ones. The CBO had estimated that an earlier version of the bill would reduce the insurance rolls by 24 million, even more than this version, but it pointed out today that the average policy would cover less under the newer bill. It also suggested that in about one-sixth of the country, insurance markets for workers who don’t have coverage through the government or their employers could get extremely messed up. And it provided plenty of interesting speculation about deficit reduction, insurance markets and out-of-pocket payments under the AHCA.
But the basic thrust of the Republican effort to repeal and replace Obamacare has not changed much, and it’s basically Captain Obvious material. The GOP wants to take money that the government has been spending on the poor and working class—mostly for expanded Medicaid coverage or tax credits to help moderate-income families afford their premiums—and give it back to high earners.
You don’t have to be a health-care expert to recognize that Obamacare did the opposite; it raised taxes on the rich to expand coverage for the non-rich. Back in 2010, Republicans actually predicted more Americans would lose their coverage under Obamacare, but the ranks of the uninsured have decreased by 20 million since then. And Americans who were already insured now have assurances that they won’t lose their coverage if they get sick or get discriminated against for having pre-existing conditions. Obamacare has had plenty of glitches, especially for the small minority of Americans who don’t get their insurance through the government or their employers, but it basically succeeded in taking some of the top 1 percent’s money to improve the health security of the bottom 99 percent.
This is why Trump and his fellow Republicans have struggled so mightily to keep their promise of increasing access to health care while also keeping their promise of repealing Obamacare and reversing its tax hikes. There’s no way to cut $834 billion out of Medicaid without reducing benefits to Americans on Medicaid. GOP lawmakers have tried to plug some of the holes in their plan with extra dollars—a $100 billion fund to help states address coverage gaps, a mere $8 billion for a “high-risk pool” to help sick Americans avoid soaring premiums—but their overall push has been to reduce health spending in order to reduce taxes. Their beatdowns from the CBO have reflected that. And if Senate Republicans take a similar approach, their bill will get a similar CBO drubbing.
Republican critics have raised some legitimate questions about Obamacare’s insurance reforms: whether young people should have access to cheaper and less comprehensive plans, whether sick people should shoulder more of the cost burden, whether federal aid has been skewed too much toward the poor at the expense of the middle class. Some of Obamacare’s other sweeping reforms—like its historic efforts to control costs and transform the delivery of care—have barely even been mentioned in the current debate, but they’re worthy of serious discussion as well.
The thing is, it feels silly to delve into the nuances of the American Health Care Act’s effects on nongroup insurance and accountable care organizations when what’s really being contemplated is a gigantic redistribution from health to wealth. Health care reform isn’t entirely about money, but a big part of it is about money. If the feds pay less to subsidize insurance premiums, most people who lose the subsidies will either pay more on their premiums or lose their insurance. Less generous spending produces less generous benefits. There’s nothing complicated about that.
Many principled conservatives believe that letting job creators keep more of their money would benefit the entire economy, and that it isn’t government’s job to meddle in insurance markets to make sure everyone gets everything they want. The CBO has nothing to say about arguments like that. But Trump and other Republicans have tried to claim that less will somehow be more, that Medicaid recipients won’t be hurt by Medicaid cuts, that people with pre-existing conditions will be just as secure without guarantees. The CBO exists to expose arguments like that.
Any effort to transform one-sixth of the economy will inevitably be riddled with complexity. But it’s not always necessary to overthink this stuff. Trump promised to expand access to health care; the CBO just provided 23 million reasons why his plan won’t do that. Nobody knew health care could be so simple.