a cut of taxes that are painless to the small percentage of people who have to pay them — a 0.9 percent Medicare surtax, and 3.8 percent tax on net invested income for couples earning more than $250,000 a year.
.. And it’s not as if there’s been a great hue and cry to repeal those tax increases. “My wealthy clients barely noticed the taxes resulting from the Affordable Care Act and have not needed to make lifestyle adjustments,” wrote the Forbes contributor Carolyn McClanahan, a financial planner.
I bet if you asked rich people if they wanted to cut off health care for millions of their fellow citizens in exchange for a bit more money at the end of the year, most of them would say no, that’s crazy. Taxes don’t register among the top concerns of people, in poll after poll.
Why such a cruel bill, then?
.. “We’re talking about a great, great form of health care,” President Trump said at midweek, with all the conviction of someone peddling the fraud of Trump University.
And you have a Congress that was largely paid for by influential groups for whom tax cuts are the only reason to get out of bed in the morning. Still, we have a moment of rare consensus in this country: An overwhelming majority hates the Republican overhaul. No state in the union has voiced majority support.
The Good, the Bad, and the Senate Health-Care Bill
It is a function of some things they’ve come to prioritize about the individual health-insurance market and Medicaid, and some things they’ve learned about the intricacies of the Byrd rule and Senate procedural constraints.
.. After seven years of saying they want to repeal and replace Obamacare, congressional Republicans have been forced to confront the fact that many of them, perhaps most, actually don’t quite want to do that.
.. That doesn’t mean that most of them never did. The case for repeal was strongest in the three or four years between the enactment and implementation of Obamacare. As more time passes since the beginning of implementation three and a half years ago, and more people’s lives become intertwined with the program for good and bad, the case for addressing Obamacare’s immense deficiencies by repeal weakens
.. I still think it is very much the case that the cause of good policy (almost regardless of your priorities in health care) would be better served by a repeal and replacement, with appropriate transition measures, than by this sort of tinkering — you’d get more coverage, a better health-financing system, and a more appropriate role for government.
.. The president has been an additional unpredictable political constraint — as the more coherent of his musings on health care have all suggested he is not comfortable with repealing and replacing the law, or at least is unfamiliar with the tradeoffs involved and unhappy when he learns about them.
.. But another thing Republicans have learned in these six months is that Donald Trump is an exceptionally weak president, probably the weakest of their lifetimes, and he is likely to accept whatever they do. He’ll celebrate it, sitting himself front and center while they stand around him awkwardly. He’ll praise it wildly and inaccurately. And he’ll sign it — even if pretty soon thereafter, in the wake of bad press, he tries to distance himself from it on Twitter and calls them names.
.. It is pegged to a less comprehensive insurance model and will both cost less and leave more room for more variation in insurance design — though this obviously means it will be less valuable and helpful to some of the people now getting subsidies.
.. Where today, people newly covered by Obamacare’s Medicaid expansion (who tend to be childless adults with relatively higher incomes than the non-expansion population) are funded by the federal government on much better terms than the traditional Medicaid population (which tends to include more women with children and people with even lower incomes), the Senate bill would gradually equalize funding for the two groups, effectively shifting Medicaid’s focus back to the most vulnerable of its beneficiaries.
.. the Senate bill would provide an income and age-based subsidy that would allow these lowest-income individuals to afford at least modest insurance coverage in the individual market.
.. the Senate bill as written would probably mean that Medicaid would cost the federal government about 30 percent more ten years from now than it does today (as opposed to about 65 percent more under current law), and would cover something like the same number of people at that point as today (as opposed to 10 million more under current law)
.. once states got their bearings about just how much it would allow them to do, we could see some genuinely different approaches to health-insurance regulation among the different states — with blue and red models, rural and urban approaches, and more and less competitive systems.
.. alters a portion of a broader pre-existing statute. But it is very broad. In its scope and structure, this redesigned waiver would be unlike anything else in American federalism — which also means we don’t know how it would work. Those of us inclined to look favorably upon a bottom-up, experimental mindset in policy design will be inclined to think the best of the possibilities here.
.. it looks like this provision would render any insurer who offers an individual-market plan that covers abortion in a given state ineligible to benefit from the stability fund in that state. It seems to me, though I can’t say I’m sure, that this would effectively mean that no insurance plans in the individual market would cover abortion. It could easily even mean that California, which has a state law requiring individual-market plans to cover elective abortion, would have to repeal that law or else forgo access to the stability fund.
Understanding Republican Cruelty
The basics of Republican health legislation, which haven’t changed much in different iterations of Trumpcare, are easy to describe: Take health insurance away from tens of millions, make it much worse and far more expensive for millions more, and use the money thus saved to cut taxes on the wealthy.
.. Meanwhile, taxes that fall mainly on a tiny, wealthy minority would be reduced or eliminated. These cuts would be big in dollar terms, but because the rich are already so rich, the savings would make very little difference to their lives.
More than 40 percent of the Senate bill’s tax cuts would go to people with annual incomes over $1 million — but even these lucky few would see their after-tax income rise only by a barely noticeable 2 percent.
.. So it’s vast suffering — including, according to the best estimates, around 200,000 preventable deaths — imposed on many of our fellow citizens in order to give a handful of wealthy people what amounts to some extra pocket change.
.. I think there are two big drivers — actually, two big lies — behind Republican cruelty on health care and beyond.
First, the evils of the G.O.P. plan are the flip side of the virtues of Obamacare. Because Republicans spent almost the entire Obama administration railing against the imaginary horrors of the Affordable Care Act — death panels! — repealing Obamacare was bound to be their first priority.
.. Republicans, through their political opportunism and dishonesty, boxed themselves into a position that makes them seem cruel and immoral — because they are.
.. this story began with a politically convenient lie — the pretense, going all the way back to Ronald Reagan, that social safety net programs just reward lazy people who don’t want to work. And we all know which people in particular were supposed to be on the take.
.. What it does — punish the poor and working class, cut taxes on the rich — is what every major G.O.P. policy proposal does. The only difference is that this time it’s all out in the open.
.. remember this moment. For this is what modern Republicans do; this is who they are.
Free the Obamacare 15 Million
They’re not ‘losing’ insurance; they just won’t be forced to get policies they don’t want.
.. That’s not quite accurate. CBO doesn’t believe that millions will “lose” their insurance in 2018. Instead, the agency thinks that millions will happily cancel their coverage — even those who get it for free. The reason: The Senate bill would repeal the Obamacare tax penalty on the uninsured, known as the individual mandate.