I've spent part of the evening reading through the bill. It is not, in fact, either a repeal or a replacement of the ACA; its relative brevity depends on the fact that it is mostly a modification of that law. A true repeal could have been much briefer; a true replacement would have had to have been much longer.

There are some good things about it, although some of them are trivial. It is clear that the Congress has been listening to the states and taking advice on what works and what doesn't, which is good. Some of that advice has been silly, like the insistence on a provision allowing states to strip Medicaid from high-dollar lottery winners. That's one of those problems that may look bad in the papers, but it can't possibly come up often enough to really merit anyone's attention. Still, trivialities aside, clearly Congress consulted with the states about the problems they'd faced implementing the ACA, and incorporated those thoughts into the bill.

Bad things appear to be included as well, although it's hard to say how bad they really are. I'm seeing equally confident exclamations from left-leaning sites that the AHCA's costs cannot be known, because the CBO hasn't scored it and nor has anyone else reputable; and also that the cost of various "pre-existing conditions" will go up by this-or-that very precise figure. Probably the first of these is true, and the figures are all made-up.

That in turn suggests that the Republicans did not learn the most crucial lesson of the ACA, which is that you should never pass a major piece of legislation whose effects you haven't taken the time to fully understand. Bad consequences are almost certain, and any consequences -- or even accidents that can be painted as consequences -- will now belong to the Republicans, or anyway will if they manage to get this through the Senate and signed by President Trump.

On the first pass, I'm not really sure what to think about it. On the one hand, Obamacare has been terrible for rural America. Breaking the seal on making changes to it would be worth doing, even if the changes aren't great. Henceforth Democrats won't oppose any changes because they're trying to 'preserve the Obama legacy'; they can support changes in terms of 'replacing/repairing Trumpcare.' Thus, we would be freer as a nation to think and adjust to the bad aspects of this bill as well as the Obamacare legacy bill.

On the other hand, a lot of this looks like it's unlikely to reduce anybody's health care costs -- though it will cut taxes for some, and raise costs for others (especially the sick and the poor). I think the Feds should get out of the health care game more or less entirely, even turning the VA into quiet grants to veterans to let them pursue private medical services. This is not a step in that direction. It's also not a step in the direction of single-payer, though, and there's a chance it will at least open the game back up to easier future adjustments as necessary.

So I'm not sure what I think right now. What do you think?


douglas said...

I think at this point, it's probably better to wait and see what the Senate does with it- it may be almost entirely unrecognizable by the time their done.

jaed said...

In itself, I don't think it will change much.

It might be the first step toward reform. Or it might be the thing Republicans point to and say "Well, we repealed the ACA! What do you mean, we still have work to do?" As Douglas notes, it's too soon to say.

Anonymous said...

I think the Feds should get THE HELL out of the health care .
Feds runs up the cost of absolutely everything it touches:

Repeal, don't replace. Scortched earth please.

A Clear Illustration Of The ACTUAL PROBLEM


Grim said...

See, that article is a good illustration of the problem from the other side. The guy has not one but two good points, but he'll never persuade anyone of them because he opens with "all my opponents are thieves who belong in prison."

Just like Lewis, if you accept his setup of the way to think about the moral arguments involved, then the conclusion does follow. What do you do when people don't accept that basic setup -- when they say, for example, that they reject a duty to die if you can't afford your medical bills and thus support current law (which imposes duties on others that help the very sick survive)?

Electing to despise them makes sense, just as it makes sense when they elect to despise him. They'd think your guy is a moral monster for equating trying to survive with fraud and theft; he thinks they're frauds and thieves. Both sides have come to conclusions that justify despising their opponents.

Which is too bad, because he really does have a good argument -- that the Federal government and big insurance companies largely create this problem of unaffordable health care, and thus that the right answer lies in the market. If he's right, the guy who needs $70,000 a year for care is a victim as much as he's anything else. He doesn't need seventy grand, he needs the care. The care only costs seventy grand because of other people, and especially these institutions. So how do we get to the place where even serious chronic illnesses are really manageable costs? That's the winning argument, not the analogy to theft.

Grim said...


Let me turn you idea around. I was reading the bill with care to try to decide what to suggest to my Senators about how to change it. Waiting for the CBO score could be helpful but, in general, what do you (and the others here assembled) think would be good changes to suggest to the Senate?

E Hines said...

One of the only two viable plans is Ryan's original schedule of Part I essentially the original House bill that was pulled at the last moment, Part II Tom Price's rules changes at HHS, and Part III finish the repeal and replace, which would a knock down drag out fight in the Senate to pass the thing. That may still be viable, despite the changes done to the Part I bill.

The other viable plan, the answer to your question, is for the Senate to eliminate the virtual filibuster on all bills relating to budgeting, revenue, and spending--force actual filibusters where each filibusterer physically talks for as long as he can, and then pass repeal and replace in two bills along party lines.

Eric Hines

douglas said...

Grim, honestly, I wish I had a clue, but this is such a mess. In the greater sphere of the health insurance issue (we should stop referring to it as a "health care" issue, it isn't), I think we need to see health insurance detached from employment- no idea how to do that though. Tort reform has to happen- so much of the issue and expense here has to do with the lawyers. Mostly I think let's leave it to the states. I keep saying that what works in Manhattan is probably not the right answer for Manhattan, Kansas. Costs are astronomically different, people's needs and priorities are different...

The biggest reason I have no suggestions is that I don't know well enough the way to make things work politically. You can know what the system needs done to it, but that's not enough- you have to also know how to get it through the political system, and that's a mysterious science to me.

E Hines said...

the greater sphere of the health insurance issue (we should stop referring to it as a "health care" issue, it isn't)

We certainly can't call it health insurance; the present regime has nothing to do with insurance. With premiums demanded to be set independent of the risk being transferred, what we have is Federally mandated, private/public funded health plan welfare.

I think we need to see health insurance detached from employment....

This is one of the reasons Trump wanted to do repeal and replace before reforming the tax code. Employer-provided insurance plans (and "full dental") began as competitive perks to attract quality employees. Then the employer and union lobbyists got Congress to make the employers' costs tax deductible. The best way to divorce actual health (and dental) insurance from employer provision from the tax code. Separately from that, that tax perk is politically hard to get rid of.

In parallel with that, actual insurance plans need to be saleable across state lines--so a Manhattan employee, or any other person, can buy a plan that suits him from an insurance company operating in Manhattan, KS. That's going to be difficult to achieve, too.

Eric Hines