AHCA is Paul Ryan’s dystopian vision for American health care

The Congressional Budget Office predicts that the House plan to repeal and replace the Affordable Care Act would, if passed, dis-insure 14 million Americans next year. By 2016, relative to current law, the non-partisan agency tasked with evaluating the effects of legislation estimates that as many as 24 million people would be without health insurance coverage—a remarkable whiplash from the recently unprecedented high rates of coverage. By that time the nation would return to abiding over fifty million of its citizens going without affordable access to the health care system.

Those who stand to lose the most in the process are older, sicker, and less-wealthy Americans, as well as those living in high-cost regions. Moreover, this doesn’t even begin to address the untold numbers of vulnerable folks that would continue to be denied coverage after 2026 thanks to a harshly-reformed, per-capita cap-constranted Medicaid program. For those of us who believe health care is a human right, or that the United States should join the rest of the developed world in providing universal coverage, the potential for the Republican’s American Health Care Act is an intensely apocalyptic turnaround from the imperfect step forward that Obamacare represented.

“But wait!” the Republicans would say, the CBO can’t account for what’s being described as phases two and three of a master plan to radically innovate away every opioid addiction, broken-arm bankruptcy, and disabled newborn. Yet those next steps amount to administrative and regulatory actions taken by Health and Human Services (like the legally dubious move of relaxing the essential health benefits portion of the ACA that can’t pass budget reconciliation rules, which would allow insurance companies to sell skimpier plans with fewer benefits), and some vague future legislation that wouldn’t face current Senate filibuster-proof constraints of today (including things like tort reform, and the primary goal of allowing coverage to be sold “across state lines,” which would produce a national race to the bottom in terms of insurance quality as companies all settle in the state with the least amount of regulation and oversight).

Now I’m just some random food service dude who occasionally types words on the internet in his free time but there’s at least one other person, much closer to this, who’s not imbibing the kool-aid of current GOP talking points:

“Hugh, there is no three-phase process. There is no three-step plan. That is just political talk. It’s just politicians engaging in spin. This is why. Step one is a bill that can pass with 51 votes in the Senate. That’s what we’re working on right now. Step two, as yet unwritten regulations by Tom Price, which is going to be subject to court challenge, and therefore, perhaps the whims of the most liberal judge in America. But step three, some mythical legislation in the future that is going to garner Democratic support and help us get over 60 votes in the Senate. If we had those Democratic votes, we wouldn’t need three steps. We would just be doing that right now on this legislation altogether. That’s why it’s so important that we get this legislation right, because there is no step three. And step two is not completely under our control.”

That’s Republican senator Tom Cotton, from Arkansas.

I’m just going to go ahead and say he’s right. There’s nothing I’ve read that would indicate loosening EHBs or allowing insurance to be sold across state lines would put a significant dent in the massive increase of uninsured the AHCA will deliver. Tort reform, which would seek to limit the amount of monetary rewards in medical malpractice lawsuits to theoretically remove the physician incentives for expensive and unnecessary procedures, is not a primary driver of rising health care costs. These aren’t moves meant to correct the damage wrought by phase one, but the ticking off of years-long bullet points that conservatives have always wanted in health care reform.

More than that, though, this effort represents a broader deployment of contemporary conservative ideology on how we deliver and receive health care. Think about Paul Ryan’s recent rolled-up sleeves moment. It was well-covered in large part due to his defense of the bill from attacks on the right, as much of the it is a result of basic realities in the House and Senate. But contained within this rebuttal was a simple statement that undergirds his motivation—a moment that was, ostensibly, rightly derided for his seemingly misunderstanding the whole point of health insurance:

It’s absolutely true that this is exactly what happens in every other insurance structure. Yet Ryan’s words do make a lot more sense to me, from his perspective, if you replace ‘healthy’ with ‘wealthy,’ and ‘sick’ with ‘poor.’ Repealing the ACA would be an impressive tax cut for the top two percent of income earners. The AHCA even includes a specific tax cut for insurance executives. His plan is a massive redistribution of wealth and security—from the bottom upward. That’s exactly what happens when you don’t consider public insurance as a legitimate scheme to provide benefits.

The vision Paul Ryan presents isn’t one of a utopian, market-driven universality in health care. It’s a dystopian introduction of the idea that the only legitimate type of health insurance is voluntary, vastly unequal, association with private capital. The healthy don’t pay for the sick. The wealthy definitely don’t subsidize the poor. Instead the lucky ones get to pay for imperfect access to care, while the rest wither away as losers in a rigged game.

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