"If you told me ten years ago where we would be, I'd be in a dream. I'd be doing backflips," Paul Ryan said about the American Health Care Act (AHCA), which four days later was projected by the Congressional Budget Office to cost 24 million people their health insurance by 2026. Last Thursday, the AHCA moved to the House Rules Committee, which is the final step before the bill goes for a full vote on the House floor and a chance to perform the legislative balancing act of making the bill more attractive to the must-have-40-vote Freedom Caucus, a group of far-right Republicans who dislike the AHCA because it doesn't fully repeal Obamacare, and moderate Republicans who don't want to hang their poor and elderly constituents out to dry.
What would life look like if the AHCA becomes the law of the land? Well, it would indeed be backflipping good news for the young, healthy, and well-compensated, so long as they don't grow old, get sick, or become poor. Here's what the rest of America might expect.
People living near poverty will lose their health insurance.
It's not clear what poor people ever did to Republicans, other than vote them into office, but the AHCA would do things to the most vulnerable and poor that almost seem scientifically engineered to ruin their lives. (And as we've pointed out before, even if this aspect of Trumpcare doesn't affect your insurance situation, it risks directly affecting your health, since a substantial portion of the humans you interact with on a daily basis stand to be less healthy.)
First, consider that more than 70 million of the most vulnerable Americans are covered by Medicaid, the government insurance program that Obamacare extended to 11.2 million people who make just above the poverty line. By 2020, the AHCA will revert to the older, more stringent eligibility limits and impose a cap on how much is spent on each person. In Colorado, for example, this will almost certainly cause a funding crisis—vanishing $340 million in the first year and $14 billion in the first decade—and 600,000 people would lose their healthcare. By 2026, 14 million fewer people will be enrolled in Medicaid—people who are unlikely to afford insurance any other way.
What about the people lucky enough to stay on Medicaid? Well, some will no longer be eligible for essential health benefits, which Obamacare requires plans to cover if you go through an exchange or a small employer, and includes things like prescription drugs. And after the AHCA goes into effect, Medicaid will not be allowed to fund Planned Parenthood for a full year, which the CBO predicts will save $234 million—but not really, since it will cost another $77 million in additional births. These numbers also don't account for women who will not be able to get life saving services like cervical cancer screenings.
Why are Republicans waging a war on the poor? Do they really believe, as Roger Marshall (R-KS) says, that the poor "just don't want health care"? The answer gets a little clearer if we understand that the ACHA isn't a health care plan first and foremost; it is a "tax relief bill for wealthy people and a deficit reduction bill and it happens to use health money to get there," explains Sara Rosenbaum, a health policy professor at the George Washington University Milken Institute School of Public Health.
The old and poor will pay for the young and rich.
The Affordable Care Act, in order to live up to its name and make insurance less expensive, provided financial assistance to low-income people. "The AHCA would turn that on its head," says Cynthia Cox, associate director for the program for the study of health reform and private insurance at the Kaiser Family Foundation. "The AHCA takes money from lower income people and gives it to higher income people and from older people to younger people."
Finally! Did you know that Obamacare does not provide a single dollar in tax credits to people making $100,000? Fortunately, this national nightmare may soon be over. According to Cox and her Kaiser colleagues, if the AHCA becomes law, a 40-year-old making $100,000 in Mobile, Alabama, will get a desperately needed $500 tax credit, whereas a 60 year old making $20,000 in Mobile will see their tax credit drop by $9,235.
This would be catastrophic: The AHCA would force some older Americans living near poverty to pay an extra $12,900 a year in premiums, which the Congressional Budget Office calculates to be roughly half their income. This is a sick way for Trump to thank a demographic who voted for him. "A lot of the people who voted for Trump are the most likely to lose out in this scenario," Cox says.
Preventive health services will stop being free.
If you have insurance, you may think you don't need to worry about your essential health benefits changing, since the AHCA keeps them intact. This may seem sigh-of-relief worthy, since gutting these benefits has been a conservative dream: The earlier draft of the Republican plan got rid of them, as did the American Enterprise Institute's plan.
But they may just be making a sneakier move, one that works around the near-impossible task of wrangling enough Senate Democrat votes. How would it work? "The Department of Health and Human Services could use rulemaking to change the way essential health benefits are defined," Cox explains. For example, one of the benefits is preventive health services, but what counts as a preventive health service is defined by HHS, of which Tom Price is the secretary—the same Tom Price who opposes free birth control. Though more than 55 million women now have access to no-cost birth control, it could be taken away without a single vote, all while the makers of the AHCA play dumb.
We will invest far less in the prevention of diseases like Alzheimer's and outbreaks like Zika.
One of the less-discussed are-they-trying-to-get-us-all-killed moves in the AHCA is ending the Prevention and Public Health Fund. The Republicans have been trying to kill it for years: In 2011, they first voted to repeal it because of "wasteful, unaccountable spending," and it has been a mainstay of Obamacare repeal efforts ever since. Americans for Tax Reform call the Fund a "slush fund" that is used "to push blatantly partisan, politicized policies." Some of those "partisan, politicized" programs include Alzheimer's Disease Prevention Education and Outreach, the CDC's Epidemiology and Laboratory Capacity Program (that is, a program that helps detect and respond to disease outbreaks), and the Garrett Lee Smith Youth Suicide Prevention grant.
On March 3, 2017, 500 organizations wrote to President Trump, warning him that eliminating the fund would be "disastrous to the CDC budget and programs" and reminding him of the public health threats of the opioid epidemic and the recent Zika outbreak. If there is a disease outbreak under the AHCA and the CDC is weakened, we may find out just how meaningless man-made borders really are.