After repeatedly vowing to replace Obamacare with something “great,” President Donald Trump’s health care bill is finally set for a vote in the House of Representatives.
Thursday’s vote marks the third attempt to get Trumpcare through the House; previous efforts failed because Republicans couldn’t marshal enough votes between moderates, concerned about projections that the bill would cause their constituents to lose coverage, and hard-right conservatives, who objected that the bill didn’t go far enough.
This time, however, projections show the bill having enough votes to pass the House (after lawmakers capitulated to the right, such as in removing protections for those with pre-existing conditions.)
Yet for a bill that supposedly fulfills Trump’s campaign pledges on health care, it still breaks almost every one of his promises to voters — from how many people it will cover, to how much it will cost, to how it will treat vulnerable populations like women and the elderly.
Tens of millions of Americans lose health insurance coverage
Republicans are rushing forward on a vote without a score from the nonpartisan Congressional Budget Office, which means there’s no official estimate of how this exact version of the bill will impact coverage levels.
According to the CBO’s analysis of an earlier version, however, Trumpcare would cause 24 million people to lose health insurance by 2026. According to the White House’s analysis, that number is even higher, at around 26 million.
While a lot of attention has been given to an amendment adding an extra $8 billion for high-risk pools, in reality, Trumpcare 3.0 is largely unchanged. It’s a $1.2 trillion health care bill, and the extra money alters the bill financially by only 0.66 percent. The new bill also guts protections for pre-existing conditions, which would likely drive uninsured numbers even higher.
Still, with lawmakers unwilling to wait for an estimate on the tweaks, we have to rely on the CBO’s estimate on the previous bill, which makes it clear that the base legislation would cause tens of millions of Americans to lose health insurance.
Despite what you hear in the press, healthcare is coming along great. We are talking to many groups and it will end in a beautiful picture!
— Donald J. Trump (@realDonaldTrump) March 9, 2017
Trump repeatedly promised voters his health care bill would not cause people to lose insurance, and in fact would insure more people than Obamacare — up to “all Americans.”
“We’re going to have insurance for everybody,” Trump told the Washington Post as president-elect. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
It was a promise he also made during his campaign. At an MSNBC town hall in February 2016, host Joe Scarborough asked Trump if “all Americans will get health care of some sort.” Trump responded, “we’re going to take care of them. We’re going to take care of them. We have to take care of them. Now, that’s not single payer. That’s not anything. That’s just human decency.”
Medicaid gets slashed
According to the CBO score, Trumpcare would cut Medicaid spending by a whopping $880 billion over the next decade.
The bill also threatens Medicaid’s protections for seniors and those with disabilities by placing a cap on federal spending per person for certain groups of people — such as the elderly and children. That means the program, which formerly covered any health care costs incurred, would be have a limit on how much it would cover, even for those who retain their insurance.
I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid. Huckabee copied me.
— Donald J. Trump (@realDonaldTrump) May 7, 2015
Trump, by contrast, made protecting Medicaid a central promise of his campaign. In the speech announcing his candidacy, Trump promised to “save Medicare, Medicaid, and Social Security without cuts.”
He repeated the claim throughout the years-long campaign, promising voters in Florida that “we’re gonna take care of Medicaid and Medicare,” and telling voters in Pennsylvania shortly before the election that his Democratic opponent Hillary Clinton “wants to knock the hell out of your Medicare, Medicaid. And I’m going to save them, OK?”
Protections for pre-existing conditions are gutted
One of Obamacare’s most popular provisions is a measure preventing insurers from denying those with pre-existing medical conditions health insurance, or from charging them exorbitant rates for coverage. Trump repeatedly promised to maintain protections for those with pre-existing conditions.
“Will people with pre-existing conditions be able to get health insurance?” Anderson Cooper asked him at a campaign stop. “Yes,” Trump replied.
“You’re going to see pre-existing conditions and everything else be part of it, but the price will be down, and the insurance companies can pay,” Trump said at a GOP debate in Texas. “Yes, they will keep pre-existing conditions, and that would be a great thing. Get rid of Obamacare, we’ll come up with new plans. But, we should keep pre-existing conditions.”
The current GOP plan, however, would allow states to opt out of providing these protections, leaving people with pre-existing conditions vulnerable to paying thousands more for health insurance. States could also opt out of requirements that health insurance plans cover Obamacare’s prescribed essential health benefits (which include such basic things as covering hospitalizations, medication, and trips to the emergency room), and could opt to charge older people more than younger people simply because they’re older.
In states that waived such protections, people with pre-existing coverage would have to continuously maintain insurance to avoid being charged exorbitant rates for coverage, or else risk being kicked into a “high-risk pool” for those with illnesses. And while Republicans are touting those pools as a solution for people with pre-existing conditions, history shows they don’t even come close to Obamacare’s protections.
“The history of high-risk pools demonstrates that Americans with pre-existing conditions will be stuck in second-class health care coverage — if they are able to obtain coverage at all,” Andrew W. Gurman, president of the American Medical Association, told CNN.
After seven horrible years of ObamaCare (skyrocketing premiums & deductibles, bad healthcare), this is finally your chance for a great plan!
— Donald J. Trump (@realDonaldTrump) March 24, 2017
Take House Speaker Paul Ryan’s home state of Wisconsin: In 2011, 21,000 people were enrolled in the state’s high-risk pool. They paid double the premiums of a comparable individual market plan, and had a $2,500 annual deductible, according to a CNN analysis. Yet they had a lifetime benefits cap of $1 million, and weren’t covered until six months after enrolling. And that’s if you could get in: most states with high-risk pools also had a long waiting list.
Republicans claim that by adding $8 billion to fund high-risk pools in the latest iteration of Trumpcare, they’re ensuring that people with pre-existing conditions will be covered. But not only has history proven that such high-risk pools hurt vulnerable populations, that money doesn’t go near far enough: according to Kaiser Family Foundation Senior Vice President Larry Levitt, $8 billion might cover “a few hundred thousand high-risk enrollees, out of millions who might need it.”
Even under pretty conservative estimates, a minimally adequate high-risk pool could cost $25 billion per year nationwide.
— Larry Levitt (@larry_levitt) May 3, 2017
According to a recent analysis by the Center for American Progress, as it stands, the health care bill will be $200 billion short of the funding it would need to adequately run high-risk pools over the next 10 years — meaning the much-lauded $8 billion is just a drop in the bucket, and those with pre-existing conditions will likely again be facing sky-high deductibles, waiting lists, and gaps in coverage.
Being a woman becomes a pre-existing condition
Another of Trump’s promises was that his health care plan would be great for women: “And by the way, I’ll take care of women with women’s health issues far better than Hillary Clinton, who’s a total phony,” he told Wolf Blitzer in a CNN interview.
“Nobody is going to be better on women’s health issues than Donald Trump” he claimed at a New Hampshire campaign stop.
Trumpcare, however, would be devastating to women’s health care. Women, who make up the majority of low-income pools and those on Medicaid, would be disproportionately represented in the population losing insurance coverage. Trumpcare defunds Planned Parenthood, which is a primary health care provider for millions of women and low-income Americans, and would make abortion coverage expensive even for women on private insurance plans.
What’s more, the move to repeal protections for pre-existing conditions means women and others who experience gender-based violence could once again be punished for it. In Trumpcare 3.0, rape, sexual assault, postpartum depression, Cesarean sections, and surviving domestic violence all are considered pre-existing conditions. As a result, women could end up paying more for their insurance coverage, or being unable to afford it altogether, because they’ve been assaulted in the past.
Because the bill also gives states the choice to opt out of Obamacare’s essential health benefits, women could also end up with plans that don’t cover maternity care, gynecological care, mammograms, or neonatal health care.
Prior to Obamacare’s requirement that health insurance plans cover maternity care, for example, 62 percent of plans on the individual market didn’t include it. Only nine states chose to mandate maternity coverage. And, often, women were forced to pay more for their plans than men anyways — even though these plans didn’t include coverage essential to women’s health care.
It will cost more
Chief among Trump’s promises — and Republicans’ priorities — was a vow to lower the cost of health care. The most common complaint with Obamacare is that some Americans, slammed with high premiums and deductibles, can’t actually afford or use the insurance they’ve purchased. The trouble is, Trumpcare only makes it worse — despite what Trump and congressional Republicans claim.
“Great points are being won and lost, and great points are being won that are going to lower premiums and make our health care incredible,” Trump said in early April. As president-elect, he promised the Washington Post that his plan would include “lower numbers, much lower deductibles.”
Trump repeated that promise routinely on the campaign trail, telling voters his fix would lower the cost of health care for both citizens and the government.
“We’re gonna bring down the price of health care. We’re going to bring it down big,” Trump said in a New Hampshire campaign stop.
According to the CBO score, however, over the first two years health care premiums would likely rise between 15 and 20 percent. After that, they would drop — but only because older and sicker Americans would be priced out of insurance and leave the insurance pool, and because people could buy plans with far skimpier coverage.
Older Americans, meanwhile, could face skyrocketing costs — 20 to 25 percent higher.
And, while Trump, Ryan, and other Obamacare critics have bashed Obamacare’s model of low premiums (what you buy upfront) and high deductibles (what you pay for care), their plan is actually likely to shift more Americans onto such plans — putting more people in the position of having insurance but not being able to afford to use it.
Actually, according to an analysis by Drew Altman, president and CEO of the Kaiser Family Foundation, Americans are actually likely to pay more on an average plan under Trumpcare than they would under Obamacare.
Wealthy Americans get a tax cut
One oft-overlooked promise Trump made as a candidate was that he would reform the tax system such that purchasing health insurance is offset with tax credits. Specifically, he said he would “allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system.” As he said on his website, “businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions?”
Trumpcare does replace Obamacare’s system of subsidies with fixed tax credits — except those tax credits fall far short of fully covering health insurance premiums, and are in fact less generous overall than the allotments under Obamacare. If you’re young, healthy, and relatively well-off, Trumpcare could end up being a better bargain; but the flip side is that older, sicker, and poorer Americans may end up paying thousands more, or likely be unable to afford health insurance at all.
One group that definitely stands to benefit, however? Rich people.
“We find that the AHCA’s changes to federal taxes and health care benefits would be very regressive: taking both tax reductions and benefit reductions into account, the average high-income family would be significantly better off and the average low-income family would be significantly worse off under the AHCA,” a joint analysis from the Urban Institute’s health policy center and the Urban-Brookings tax policy center found.