Republican Party leaders are trying furiously to find 50 votes for some kind of legislation that would, one way or another, repeal the Affordable Care Act.
The big focus of their efforts are a handful of relatively moderate senators from states where Obamacare has had a particularly strong impact on coverage. And although the campaign includes some old-fashioned political pressure, with President Donald Trump set this week to visit two of those states (Ohio and West Virginia), GOP leaders are also trying to use persuasion. In particular, they are still trying to convince those holdout senators that repealing the 2010 health care law wouldn’t cause their constituents to suffer.
So far those senators have been skeptical, and for good reason. The Congressional Budget Office has projected that the GOP proposals under consideration would mean between 22 to 32 million people lose health insurance, depending on the specific bill. Multiple independent experts have come to similar conclusions.
Meanwhile, a huge pile of research and data suggests that when people lose insurance, they are worse off because they end up skimping on care they need, going into debt paying for the care they get, or some combination of the two. This is particularly true for people with the lowest incomes and most serious medical problems ― in other words, the people who need help the most.
Not that it should require a bunch of academic researchers make these points. Each of the bills under consideration would drain more than $1 trillion over 10 years from Medicaid and tax credits for people who buy private insurance on their own. Obviously that is going to hurt, as anybody now depending on those programs for insurance can attest.
But apparently neither data or common sense is enough to stop Trump administration officials, Senate leaders, and their outside allies from making their case. Publicly and privately, they continue to say repeal wouldn’t cause a lot of pain. And lately they have been leaning heavily on two arguments in particular:
Claim: CBO Projections Aren’t Reliable
Last weekend, two administration officials wrote a Washington Post op-ed dismissing the agency’s predictions as “little more than fake news.” It was merely the latest volley in a campaign to discredit the CBO that Republicans have been waging ever since it first issued a devastating projection of what the initial legislation, in the House, would mean for insurance coverage.
These attacks typically focus on a prediction that CBO genuinely got very wrong. The agency vastly over-estimated enrollment in the Affordable Care Act’s exchanges. What Republicans never acknowledge is that on the most important prediction, about the total change in the number of Americans with insurance, CBO was extremely close ― especially if you adjust the projection for the Supreme Court’s 2012 decision giving states extra leeway to avoid expanding Medicaid.
Could CBO be making a bigger error now? Sure. Projections are subject to uncertainty, as the agency itself goes out of its way to stress.
But error can run in both directions. And even if CBO has overestimated the coverage loss by a factor of two, an unprecedented error, that would still mean the current version of the Senate bill would lead to 11 million fewer people with health insurance. That would still be a very big number ― which is to say, it would still represent a whole lot of Americans struggling with medical bills if that repeal bill becomes law.
Oddly, CBO’s critics in the Republican Party don’t seem to realize the potential fiscal implications of their argument. If actual coverage losses under the GOP plan would be smaller than the projections suggest, it’s also possible the federal government would end up spending a lot more money on Medicaid and insurance tax credits.
“In a sense, proponents of repealing and replacing the ACA are trying to have it both ways,” Larry Levitt, senior vice president at the Henry J. Kaiser Family Foundation, said. The Republicans are “criticizing CBO for over-estimating the effect of the individual mandate and the losses in coverage, while benefiting from projections of big spending reductions that pave the way for tax cuts.”
Claim: Mostly People Would ‘Choose’ Not To Be Covered
House Speaker Paul Ryan (R-Wis.) last week repeated an argument he and other Republicans have made many times before. He called the CBO’s most recent coverage prediction a “bogus number” because people will “choose not to buy” insurance.
The basis for this claim is that, according to the CBO, the vast majority of coverage losses in the first two years of passing repeal would be the effects of removing the individual mandate ― the financial penalty for people who decline to get coverage. And Ryan’s description certainly applies to some of those people. Absent the penalty, a significant number would opt not to pay for insurance ― particularly if, under the Affordable Care Act, they think their available options are too expensive.
But that’s not the whole story. Many people have no idea they are eligible for subsidized coverage or Medicaid until the mandate drives them to investigate options online or to consult with counselors ― at which point, these people are quite happy for the coverage.
Take the mandate away and they never take that step. In fact, there is some evidence that repeal would depress insurance enrollment because some Americans would believe, mistakenly, they could no longer get assistance. Something similar happened after welfare reform, in the 1990s, when a significant number of legal immigrants stopped applying for Medicaid even though their eligibility hadn’t changed.
Removing the mandate also has a secondary effect on the market, one that becomes more important over time. The people most likely to decline insurance are the ones in relatively good health. That forces insurers to raise premiums and, in some cases, to raise them preemptively, as many are doing right now because the Trump administration has signaled it won’t enforce the mandate aggressively.
“Saying that all of the insurance losses the CBO attributes to repealing the mandate are the result of individuals not being ‘forced’ to buy insurance is at best incomplete and in reality quite duplicitous.”
- Craig Garthwaite, health economist at Northwestern University
Republican bills would cause premiums to rise for precisely this reason, the CBO and other experts say, pricing more and more people out of the market. (Eventually premiums would come down, but only because, thanks to weaker regulations, policies would be less generous and less available to people with pre-existing conditions.)
“The insurance market components of the ACA (the mandate, the subsidies, and the ban on pre-existing conditions) all work together – they are inexorably intertwined,” says Craig Garthwaite, a health economist at Northwestern University. “Saying that all of the insurance losses the CBO attributes to repealing the mandate are the result of individuals not being ‘forced’ to buy insurance is at best incomplete and in reality quite duplicitous.”
The CBO doesn’t parse out how much each of these factors matter. But one thing clear is that, over time, effects of the mandate per se would actually recede, relatively speaking, because other changes in the Republican bill would be taking effect. Tax credits for people who buy insurance would get smaller. Federal contributions to Medicaid would decline, creating shortfalls that would lead states to cut coverage.
In 2026, CBO predicts, 15 million out of 22 million newly uninsured would be people who would qualify for Medicaid if the Affordable Care Act remained in place. By and large, these would be people who had no affordable alternatives in the private market under GOP proposals.
As Loren Adler, associate director of the USC-Brookings Schaeffer Initiative on Health Policy noted on Twitter, “the main issue is many who lose coverage w/mandate repeal would lose coverage due to other [repeal] provisions regardless.”
Reality: Honest Defenses Of The GOP Bill Aren’t Very Popular
An intellectually honest defense of Republican repeal plans is that they would mean fewer regulations of health insurance, lower taxes on corporations and the wealthy, and less government spending. Conservatives would argue these steps free up resources for other purposes and improves the economy, in ways that would ultimately matter more than making sure people have health insurance. Another intellectually honest defense of the GOP proposals is more philosophical ― that healthy and wealthy people shouldn’t have to spend as much as they do now, in order to subsidize the costs of the sick and the poor.
A different, but still intellectually coherent, argument for repeal focuses on the individual mandate specifically ― not on whether it works but on whether it should even exist. Many conservatives think it’s just plain wrong to penalize people for tuning down insurance. On that point, at least, it’s quite possible a majority of Americans agree.
Sometimes Republican leaders and their allies make these arguments explicitly. But it turns out most people think health insurance is pretty important. And now that the Affordable Care Act has made coverage more available, they don’t want to give it up, particularly if Republicans aren’t proposing to put something better in its place. That is probably why GOP leaders keep insisting their bills won’t leave millions struggling to pay for medical care, when that is exactly what those proposals would do.