The Republicans’ “repeal and destroy” mission

May 12, 2017

Dennis Kosuth and Alan Maass analyze the third-time's-the-charm version of the Republican health care bill that passed the House earlier this month.

ON MAY 4, Donald Trump, House Speaker Paul Ryan and a mob of Republican leaders gathered in the White House's Rose Garden to celebrate Trump honoring his campaign promise to "repeal and replace" Barack Obama's Affordable Care Act (ACA) in the first 100 days of his presidency.

Except that the 100-day period was already over. And the American Health Care Act (AHCA) had only just passed one wing of Congress--the Republican-controlled House by narrow 217-213 vote--which is a far cry from repealing and replacing anything given opposition to Trump-Ryancare in the Senate.

But in Trumpland, that's close enough for some self-congratulation.

The Republicans managed this not-yet-an-achievement on the third try in the House. Trump and Ryan unveiled their first proposal in early March that was already horrifying for working people--a naked attempt to gut health care services for the poor and workers in order to transfer billions of dollars to the rich through tax cuts.

But Trump-RyanCare Version 1.0 ran into opposition from the Tea Party right wing of the Republicans, organized in the so-called Freedom Caucus, which derided the AHCA as "Obamacare Lite" for not being aggressive enough in slashing everything remotely beneficial to working people in Obamacare. Ryan withdrew AHCA v1.0 before it went down to defeat. A second attempt to revive the AHCA went nowhere.

Protesters demonstrate outside the Capitol as the House passed the AHCA
Protesters demonstrate outside the Capitol as the House passed the AHCA (

But in April, Ryan--under pressure from the Trump White House frantic to accomplish something before 100 days was up--finally came up with a version of the AHCA that was acceptable to the reactionaries.

The biggest concession was to propose elimination of probably the most popular aspect of Obamacare--the new regulations on insurance companies that bar them from using pre-existing conditions as an excuse to deny coverage or charge outrageous prices. The House passed the even more destructive AHCA v3.0, though with 20 Republican "moderates"--more accurately described as "less fanatically right wing"--voting against

Opposition among Senate Republicans means the Tea Party Special version of the AHCA will be changed radically before it ever gets to Donald Trump's desk to be signed--if it ever does.

Meanwhile, the health care industry--which supported the Republican opposition to the ACA, even as it worked with the Obama administration to shape the bill to its liking--repeated its almost unified opposition to Trump-Ryancare. "America should not go backward to the time when our fellow citizens with pre-existing health conditions faced high costs for limited coverage, if they were able to obtain coverage at all," said American Medical Association President Andrew Gurman in a statement.

THE MEDIA'S attention when the House passed the AHCA was mostly focused on the removal of safeguards established by Obamacare for what the health insurance industry calls "pre-existing conditions"--which basically means any health issue from an individual's past, from cancer to chicken pox to a pregnancy.

Under the turbo-reactionary version of the AHCA, state governments would be able to seek a waiver for the ACA requirement that insurance companies charge people the same for coverage regardless of their health history. Individuals who could be discriminated against because of pre-existing conditions under the new rules would be thrown into so-called "high-risk pools" to buy policies with higher premiums.

The salesmen of the AHCA insist that people with pre-existing conditions will be protected if they maintain continuous insurance coverage from the same provider.

But this is a very significant "if." The Commonwealth Fund found that about 30 million adults had more than a 63-day gap in insurance in 2016, which under the AHCA would make them eligible for a penalty and put them at risk for higher premiums.

This is consistent with the punishment shell game common to all the versions of the AHCA: While Obama's ACA penalizes you if you don't have insurance, the AHCA would penalize you if you are uninsured and try to sign up for coverage.

Ryan and Trump rounded up enough votes from "moderate" Republicans to win passage of the bill by agreeing to add another $8 billion over five years in subsidies for people thrown into the "high-risk pools" to buy insurance.

But that's completely inadequate, say health care analysts. "Even with all the layers of funding in the bill and the subsequent amendments, the money falls short of what would really be necessary to cover the cost of people with pre-existing conditions," said Larry Levitt of the Kaiser Family Foundation.

The changes made to the AHCA go much further in giving state governments the ability to dismantle positive elements of Obamacare. For example, states would be able change the list of "essential health benefits" that the ACA requires all insurance policies to cover, including doctors' visits, hospital care, prescription drugs, pregnancy and childbirth, drug treatment and mental health services.

It's hard to say what is more absurd: that an insurance company would have to be instructed to include access to a doctor in a health plan, or that Republicans used the "states' rights" claim once employed to defend slavery and Jim Crow segregation to justify provisions of the AHCA.

But the consequences of this change could be profound. If, for example, Alabama drops maternity care from the list of essential health benefits required of policies sold in the state, a woman who wants that coverage for an obviously common health condition could be charged as much as 25 to 70 percent more in premiums.

WITH ALL the focus on the provisions that Ryan had to agree to in order to get the support of the Freedom Caucus reactionaries, less attention was paid to the lowlights that remain from AHCA v1.0.

One centerpiece from the original legislation remains untouched: the declaration of war on the Medicaid health program for the poor. The expansion of Medicaid under Obama's ACA was the main way that more people gained access to health care. Trump and the Republicans want to reverse that and more.

The AHCA would cap federal funding for Medicaid regardless of whether enrollment increases or health care costs rise, and the ACA's funds to cover more than 11 million more people would be phased out. According to the Congressional Budget Office, 14 million fewer people would be covered under Medicaid by 2026 if the AHCA becomes law.

Even more disgusting is the bald fact that reduced spending on Medicaid would go directly into the bank accounts of the very richest people in the country. As reported in March:

The House version of the legislation would reduce Medicaid spending by $880 billion over a 10-year period from 2016 to 2017, accounting for three-quarters of the $1.2 trillion in reduced spending by demolishing the ACA. But the lion's share of the "savings" would be transferred to the rich through tax credits or the repeal of ACA's new taxes to pay for provisions like expanding Medicaid.

For example, if Republicans succeed in eliminating two additional Medicare taxes created under the ACA--an additional Hospital Insurance tax on high earners and the Medicare tax on unearned income--households with an annual income of $1 million or more would get tax cuts of $49,370 a piece. The richest 0.1 percent of households, with incomes above $3.8 million, would get tax cuts of more than $195,000 on average.

There's plenty more outrages in the AHCA, even before it was made acceptable to the Freedom Caucus.

Medicaid recipients would be barred from getting care at Planned Parenthood facilities, and--taking a page from Bill Clinton's welfare deform legislation from two decades ago--states would have the option of requiring recipients to work to qualify for benefits.

The subsidies that made mandated insurance bought from private insurers affordable for low-income people would be repealed, and insurance companies could charge older people--who, of course, are more in need of health care--as much as five times more for policies.

THE AHCA meets exactly none of the criteria that Trump promised just before taking office. He claimed the Republicans' version of Obamacare would provide "insurance for everybody," with "lower deductibles," where people covered "can expect to have great health care. It will be in a much simplified form. Much less expensive and much better."

It's little wonder that as the details of Trump-Ryancare have become clearer, Obama's ACA has become more popular. Republicans faced a wave of protests at town hall meetings in their districts earlier this year, with demonstrators demanding that the ACA be kept alive.

This isn't because people have forgotten the problems with Obamacare that outweighed the positive achievements. The biggest flaw of the ACA is that it required millions of people to buy the defective and extremely costly products of a private insurance industry dedicated to profit over guaranteeing access to care.

But the ACA has been accepted as the new floor of health care expectations. Now that people have become accustomed to a rough and cold cement floor that periodically floods, there is little desire to return to the insect-ridden dirt floor of the pre-ACA days--or to downgrade further to the AHCA's sub-basement floor covered with raw sewage.

The people who are protesting the Republicans' AHCA nightmare are right to take a stand, but we shouldn't forget that health care should be a right, and every person should have access to it. The only solution to the crisis is a single-payer, Medicare-for-all system that covers everyone.

Fortunately for Trump, and unfortunately for the rest of us, the so-called opposition party in Congress is practiced at posing neither an alternative to nor any credible threat against the Republican onslaught.

Anger at rising health care costs caused by the ACA's fatal flaws is one of the reasons why Republican demagogues like Trump were able to win support from ordinary people in the 2016 election. So you might think the Democrats would at least stand up for an alternative that attempts to improve Obamacare--or even open up a national discussion about the need for a single-payer system.

Instead, when the Republicans passed the AHCA on May 4, several dozen House Democrats celebrated by taunting the GOP for a vote that may cost them House seats in the 2018 election. With the health and welfare of millions at state, the Democrats' cynicism is infuriating.

It won't be easy to achieve a sensible health policy that every other industrialized country already has, and it's plain as day that the two parties that voted in Congress on the AHCA won't get us there. We'll need a broad and sustained struggle outside Washington if we hope to achieve this goal.

Further Reading

From the archives