Ryancare Shows GOP Only Has Slogans But No Real Policies

OK, let's call this disaster what it is. From now on, and I believe with even some Republicans assenting, this is Ryancare and it is a disaster. They had seven years to come up with a plan and this is what they produce. It is yet another example of the lack of policy substance that is at the core of the Republican party these days. Their members are so entrenched by extreme gerrymandering that they simply run on campaign on slogans. And they can get away with it.

You can read in depth analysis from people who have plenty more knowledge and experience about health care law than I do. But the basic gory outlines are this. The massive tax cuts the GOP is really looking for are realized by repealing the Obamacare taxes on wealthier Americans and the assumption that federal Medicaid spending will end up being reduced by over half a trillion dollars. The plan will cover fewer people and premiums, deductibles, and copays will skyrocket for seniors and those with low income. The Obamacare subsidies will be replaced by a tax credit that increases with age, not need. It will be indexed to the CPI+1 meaning that it will become worth less and less as the cost of healthcare rises faster than regular inflation. In addition, the tax credit does not vary by region meaning that in some rural states like Alaska, premiums will be unaffordable. The individual mandate is repealed but to encourage continuous coverage, the plan allows insurers to charge a 30% premium for enrollees who have let their insurance lapse. There are serious doubts about whether the individual insurance markets will not collapse if the plan goes into effect. It defunds Planned Parenthood in a critical blow to women's health. Lastly, it will phase out Medicaid expansion in 2020 and convert it into a block grant, essentially transferring additional costs to the states.

There are also plenty of old GOP standards that are not included in the plan, primarily because they can't be done through the budget reconciliation process that requires only 51 votes in the Senate. These old hobbyhorses include selling insurance across state lines and reducing the minimum requirements required of all health plans. It is also a parliamentary question of whether the replacement of the individual mandate with the premium charge for not having continuous coverage will pass muster as a budget reconciliation item. Changing the Obamacare rules on pre-existing conditions and allowing a family member to stay on their parent's plan until they are 26 are also not included because they would not qualify under the reconciliation process, not because Republicans actually support those policies.

More importantly, the Republicans don't have the courage of their own convictions as many of the changes don't take effect until 2020. In addition, the Energy and Commerce Committee seems intent on forcing a vote on the bill even before the CBO can score the plan, meaning we have no idea what effect the plan will have on the budget, how much out-of pocket costs will increase, and, critically, how many people will actually lose insurance under the plan.

The reality of this plan is that it actually proves that the framework of Obamacare is the only way you can reduce the number of uninsured with real health coverage, other than moving to a national single payer plan like every other industrialized country. Obmacare relies on the three-legged stool of guaranteed coverage with no penalty for pre-existing conditions, subsidies, and requirement for everyone to buy coverage. Ryancare basically maintains this framework but not nearly to the levels that exist under Obamacare. It still maintains the guaranteed coverage; it maintains subsidies by using tax credits; and it tries to force everyone to buy coverage through the penalty for enrollees who have let their insurance lapse. Regardless of what Republicans say, Ryancare validates the Democratic approach to health insurance. Of course, Obamacare was really based on a conservative alternative to Bill Clinton's health insurance initiative in the 1990s but conservatives never really wanted their own plan to be adopted.

So, if this plan has all the features of Obamacare, as Ezra Klein so aptly puts it, what problem exactly is Ryancare trying to solve? The answer is, of course, to fulfill their slogan to repeal and replace while at the same time providing a massive tax cut to their rich and corporate overlords. The only policy that matters in the plan is repealing the Obamacare taxes and eliminating Medicaid spending so there is room for further tax cuts. The rest is just dressing to appease their base who believed and continue to believe in their slogans. Policy details are meaningless because they aren't necessary to get elected. That is why Trump can discover that health policy is incredibly complicated only upon taking office and Jason Chaffetz can say people will have to choose between a new iPhone and a healthcare plan.

Already the Freedom Caucus is opposing the bill and putting forward the 2015 bill that simply repealed the ACA. Heritage has come out against the bill. At least four Republican Senators have also denounced the bill. And Trump, Pence, and Price have all said that the bill is mainly a starting point in the legislative process.

This creates a problem for the GOP in that insurance companies have to decide in April whether they will participate in the exchanges next year. There is no way that Republicans are going to be able to negotiate a deal that will be able to pass both houses of Congress in a little over one month, especially with the vociferous opposition the bill is facing even before the CBO score has come out. While the GOP plan keeps most of the provisions in place for the next couple of years, it is hard to see why insurance companies would risk participating in the exchanges since they don't know how people will react next year and their business model will be obsolete the year after.

Democrats have better be prepared make sure any collapse in the markets next year get pinned squarely on Republicans. It is the easiest attack to make. Republicans aren't ready to govern, they are just good at getting elected on campaign slogans. The Trump administration is clearly not ready and probably unable to govern. And the uncertainty that the GOP's inability to come up with a viable plan for health policy will jeopardize people's insurance next year unless Ryancare or any of its alternatives are stopped dead in its tracks. Get going Schumer, Pelosi, and Perez.