Adding to this irresponsible picture, Republicans are poised to mark up their bill without a full analysis from the Congressional Budget Office of its budgetary impact or — crucially — of how many people the proposal would (or would not) cover.
On the latter question, there is ample reason for concern. The bill would substantially reduce the amount of assistance that low-income people get to buy coverage on the individual insurance market, it would ramp up how much more insurers can charge older people relative to younger people, and it would remove Obamacare’s crucial link between actual insurance costs and the federal assistance people get. Combined, these changes would push many needy people out of the individual insurance market. Republicans claim that Americans would have more flexibility in the sorts of insurance plans on offer, including cheaper “catastrophic-only” health-care policies, but that sort of coverage, with its high deductibles and limited benefits, is hardly useful to people barely scraping by now under Obamacare’s much more generous system.
First, the tax-credit structure in the bill would not only make health care less affordable for millions, particularly those over 55, it would also destabilize the insurance markets. The ACA pegs tax credits to income levels and, when premiums rise, those tax credits rise along with them, protecting consumers against regional differences and sudden increases in medical costs.
Second, the bill drops the individual mandate. About as unpopular as vegetables are with my kids, the mandate for individuals to buy insurance nevertheless keeps premiums lower for everyone. Adding a surcharge of 30 percent for those who decide to sign up for coverage after a gap may hurt more than it would help, as it would disproportionately attract sicker people.
But the most lasting effects of this bill would be the significant steps it took toward forcing permanent changes to Medicaid and Medicare. The Medicaid changes are more obvious and dangerous. First, the bill would effectively end the popular and largely bipartisan Medicaid expansion created by the ACA, which extended care to millions of working Americans. Dropping the federal funding contribution for new enrollees after 2020 — and violating a promise the federal government made to the states — would rapidly end the expansion. In today’s world, taking away funding for such a program is the same as killing it; it’s just a different weapon.
Medicare doesn’t escape unscathed either. The bill would cut several years from the life of the Medicare trust fund, but that’s clearly no accident: The program would wind up right where “entitlement hawks” such as House Speaker Paul D. Ryan (R-Wis.) want it — in crisis. If this bill became law, the speaker would finally be positioned to change Medicare to a voucher program.