It’s hard to decide which would be the more politically damaging outcome for Republican politicians: passing the American Health Care Act, and therefore owning the premium increases and coverage losses it would cause; or not passing the bill, and therefore failing to do anything that can be framed as “repealing Obamacare.”
Each option is a political nightmare for Republicans for the same reason: Each would amount to an admission that Republicans cannot deliver what they have promised for years on healthcare.
For years, Republicans promised lower premiums, lower deductibles, lower co-payments, lower taxes, lower government expenditure, more choice, the restoration of the $700 billion that President Barack Obama heartlessly cut out of Medicare because he hated old people, and (in the particular case of the Republican who recently became president) “insurance for everybody” that is “much less expensive and much better” than what they have today.
They were lying. Over and over and over and over, Republicans lied to the American public about healthcare.
It was impossible to do all of the things they were promising together, and they knew it.
Then they unexpectedly won an election and had to face the question of whether they would break all of their promises - or only some of them.
If the AHCA passes, Republicans will have delivered on a couple of promises: lower taxes (mostly for people who make over $200,000 a year) and lower public expenditure (mostly because of Medicaid cuts, the main reason the bill could leave 24 million more Americans uninsured). All the rest of the promises will be broken.
And if they don't pass the AHCA, well, then they'll have broken all of the promises.
Either way, Republicans will have to face an angry electorate in 2018 and 2020 that did not get what it was promised. The exposure of Republican healthcare lies will do grave damage to the party, and that damage will be richly deserved.
A politics of bad faith
I want to draw a distinction between healthcare and most other issues.
Take, for example, tax policy. Even though I find some of the economic models Republicans use to evaluate taxes unconvincing, I think the tax debate is mostly conducted in good faith: Republicans sincerely believe taxes are bad morally and bad for the economy. So they roundly denounce taxes and, when they are elected, they try to lower them.
Republicans say they oppose abortion and, when elected to state legislatures, they vote for restrictions on it. They praise conservative judicial philosophies and, when elected president, they nominate conservatives to the bench.
The Republican Party is not wholly in the business of claiming to be for one thing and then doing another.
The difference on healthcare is that Republicans never had an ideology about it. So they were willing to lie, and there are two facts about the healthcare debate that a liar can exploit quite effectively until he is actually expected to make policy. People are always upset about how much healthcare costs, and healthcare is very complicated, so it is hard for voters to tell whether a politician is actually able to keep his or her promises about it.
If you went around telling abortion opponents that you would ban abortion and abortion-rights advocates that you would give abortions out free, the two sides might notice you were promising two incompatible policies. But for years, Republicans were able to capitalize on public ignorance and get away with promises that amounted to "much less expensive and much better."
Their political strategy was cynically brilliant until it led to their getting elected.
Saying one thing and doing another
The need to actually make policy is exposing the fact that Republicans made many healthcare promises they never intended to keep.
Republicans have denounced insurance plans sold under Obamacare as insufficient, because the deductibles and co-payments under some plans are so high that many people feel they can't afford care even if they are insured. But the AHCA would allow insurers to sell plans that would cover an even smaller fraction of insured people's healthcare expenses.
The Kaiser Family Foundation estimates that deductibles for an individual-market insurance plan on average would rise by $1,550 under the AHCA.
Republicans complained that premiums were too high for people to afford, and then they proposed a law that would cut premium subsidies by hundreds of billions of dollars and would leave some people near retirement age with insurance premiums of more than half their income.
But in my view, the most galling lie was about Medicare.
Early in Obama's term, Democrats sought to implement a significant expansion of subsidized health insurance without growing the budget deficit, so they imposed substantial cuts to Medicare spending as part of the Affordable Care Act.
Republicans were outraged, and they made opposition to Medicare cuts the centerpiece of their (successful) 2010 campaign to retake the House of Representatives. When Paul Ryan ran on the Republican presidential ticket in 2012, he and his running mate promised to restore the cuts if elected, out of a desire to protect seniors.
But once Ryan was actually in a position to shape legislation on healthcare that might become law, he decided to leave the Medicare cuts in place, because he would rather have the money for tax cuts for rich people.
Actually, wait, that was only the second-most galling lie. The most galling lie was when Trump said he would provide "insurance for everybody" and then endorsed a plan that would take away coverage from 24 million people, according to the Congressional Budget Office's estimates.
I told you so
Back in 2013, I wrote a column for Bloomberg View titled "There Is Still No Republican Health Policy Agenda." It began:
"There's no surer way to make a conservative health wonk huffy than by saying Republicans don't have a health policy agenda. They insist they do, and an important part of it is high-risk pools: government entities that provide subsidized insurance to people with health risks who couldn't be covered affordably in private markets."
At the time, a mini version of the AHCA debacle had played out in the House of Representatives. In one of their many symbolic votes to "repeal Obamacare," Republicans had rolled out one of their typical pieces of healthcare vaporware: those high-risk pools.
These pools can get people covered in theory, but because sick people are expensive to give medical coverage to, you need very large subsidies if you wish to make the pools both affordable to the insured and profitable for the participating insurers. That is, it's easy to establish the pool, but you need to spend a lot of money if you actually want the pool to work.
Experts will differ on exactly how much a robust, national program would cost, but the figure is somewhere in the hundreds of billions of dollars for a decade. House Republicans were proposing a "demonstration" for $5 billion.
But then-Majority Leader Eric Cantor pulled the bill from the floor before it got a vote. He wasn't going to be able to get his caucus to vote for it. It was too expensive.
The Republican commitment to high-risk pools, like nearly everything else Republicans have said about healthcare for a decade, was a lie all along.
The speaker has no clothes
Through the years, healthcare experts on the right have allowed themselves to be used as window dressing for a party that was never actually interested in taking their policy advice.
The experts would write white papers about conservative approaches to healthcare. Republican politicians would indignantly wave the white papers around and insist that they had not only one plan for healthcare but many plans, and they involved high-risk pools and selling insurance across state lines and something something patient-centered mumble mumble mumble and whatever was in the paper was going to be way better than Obamacare.
Ryan even developed an undeserved reputation as a healthcare "wonk."
But those white papers were always just paper. The plans described in them were never going to be implemented by an actual Republican government, which would not be interested in paying for the plans the papers described. The only thing Republicans ever intended to use them for was indignant waving.
It was all a lie. And the lie is finally about to be punished.