Trump's First Legislative Accomplishment Will Require Him To Lie And Harm Millions

The president's health care push pits his hunger for popularity against his hunger for victory.

With that, President Trump took ownership of the House GOP bill and simultaneously broke three major promises to all Americans, particularly older ones: 1) His promise to repeal and replace the Affordable Care Act (ACA or “Obamacare”), 2) His promise not to touch Medicare, and 3) His promise to provide insurance for everybody. Politics can lead to unusual outcomes, but reconciling the President’s public statements with his embrace of this new bill requires a suspension of reality. Let’s briefly address each of these issues and explain how facts diverge from the original promises.

The ACA is a complex law. Its insurance market reforms, new and expansive federal regulations on health insurance, expansion of Medicaid to provide health insurance to poor individuals, and subsidies to those who are near poor or lower middle class comprised detailed new programs. It is funded by new taxes, primarily on rich individuals and corporations, and by cuts in wasteful spending, primarily within the federal Medicare program. Despite its imperfections, it has covered 22 million otherwise-uninsured individuals and provided additional protections to over 100 million otherwise-underinsured individuals.

Relatively modest changes can make the healthcare insurance exchanges operate better, with more competition and better pricing. Both parties, however, have hesitated to work in a bipartisan manner on the existing legislation for fear of being perceived as abandoning their electoral base. The GOP has campaigned on repeal for seven years and, with new control of Congress and the Presidency, must demonstrate that they can govern. But upsetting the existing insurance market for tens of millions of Americans is not an easy challenge, and the proposed American Health Care Act (AHCA) would do just that. It would not, in fact, repeal the ACA, but just change it; nor would it reduce costs for the vast majority of insured Americans. It would reverse the Medicaid expansion, change the marketplaces with less financial support, and, importantly, repeal numerous taxes on industry and rich individuals.

One of these taxes, the Medicare surtax, supports the federal program that insures 55 million elderly and disabled individuals in this country. Despite President Trump’s promise not to touch Medicare, the AHCA sabotages this program, requiring a substantial infusion of cash or a reduction in benefits to continue its current operations. Repealing this tax does not improve the insurance market one bit. It is not needed for repeal. But it does benefit individuals making more than $200,000 per year and hurt individuals who rely on Medicare, and that seems to be enough.

The president famously vowed to cover everyone, yet this new piece of legislation is inconsistent with that promise The AHCA will result in 24 million more uninsured individuals, bringing us back to the pre-ACA level of uninsured in this country. Pointedly, those closest to Medicare eligibility (55-64 years of age now) will bear the greatest burden, as premium rates will be higher and subsidies will be lower for this group, causing many to fall out of the market. This will have the unintended consequence of driving up Medicare costs, as these poorly insured individuals become eligible for Medicare when they turn 65 and consume disproportionately more health care. All the while, Medicare benefits would be put at risk by the removal of the Medicare surtax.

Relitigating the election is a fool’s errand. Whether we supported the election of President Trump and/or the GOP Congress, we all need to see a functioning government and one that can help improve our health care system and the health of our nation. The ACA was always an imperfect solution in need of further work, but the AHCA represents a giant leap in the wrong direction. Those approaching and in retirement have much to lose during this debate and should make sure their voices are heard.

Howard P. Forman is a Professor of Radiology,  Public Health, Economics and Management at Yale University.