The New Yorker Magazine had a cynical yet plausible explanation of Trump’s hot and cold support of Trumpcare.  Republicans have made two promises that can’t be reconciled. They promised to repeal Obamacare, and to replace it with a terrific law that would take care of everybody. As the House Republican ad put it, they promised, “more choices and better care, at lower costs. … peace of mind to people with preexisting conditions … without disrupting existing coverage.” Those things cannot be reconciled. If Republicans repeal Obamacare, they will put in place something that not only fails to provide the better, cheaper care they have promised the country, but does not meet even the minimal threshold of access to basic care for people who currently receive it.

Politico and CNN reported that Trump has a fallback plan: Let Obamacare fail on its own, blame the Democrats , and push another Republican health-care plan two years from now.

In remarks at the Republican retreat CPAC, and on Twitter, Trump mentioned that the smartest political move would be to do nothing to improve the health-care system. Apparently that is his plan based on Trumpcare.

“I actually talked with Paul [Ryan] and the group about just doing nothing for two years, and the Dems would come begging to do something because ’17 is going to be catastrophic price increases, your deductibles are through the roof, you can’t use them, and they will come to us,” Trump said at the annual GOP retreat in Philadelphia.

 “I’m serious if we waited two years it’s going to explode like you’ve never seen an explosion,” he said. “That’s politically what we should do but we don’t want to do that.”

So Trump is betting that after promising to repeal and replace Obamacare immediately, backing a bill everyone hates, failing to make members of his own party pass it, then doing nothing for two years as Americans go broke and even die, the country is going to blame Democrats for failing to fix the health-care system.

From that standpoint, the winning play for the GOP might be to try to repeal and replace Obamacare but fail. If they are seen trying and failing to repeal the law, it might upset the base, but most Republican lawmakers will have their opposition to Obamacare on the record. And if it is to fail, it should fail quickly, so they can move on to increasing the deficit by cutting taxes.

Bob Doherty, senior vice president for government affairs at the American College of Physicians, the trade group for internists and the second-largest association of doctors in America, is taking a different approach on Twitter, blasting the bill as the worst measure he’s seen in nearly 40 years of advocacy work.

Doherty warns of “thousands of preventable deaths” if the bill passes (which checks out), as 28 million people lose coverage. He also makes the point that the long-term health consequences of the bill could be even more severe, as older people who lose insurance coverage due to skyrocketing premiums “will put off getting care until diseases are at more advanced, less treatable, & costly stage.”

In 38 years advocating for doctors, patients I’ve never seen a bill that will do more harm to health than #AHCA bill being voted on Thursday

It will take coverage from millions of most vulnerable: the poor,sick & old. It will raise premiums & deductibles by thousands of $.

It will make the opioid epidemic worse by ending requirement that Medicaid cover substance use treatment.

It cuts Medicaid funding by 25%; states will have no choice but to cut coverage & benefits and/or raise taxes, cut provider pay.

It cuts funding to @CDC to prevent spread of infectious diseases like flu and Zika.

Proposed work requirement for Medicaid punishes those who can’t work because they are sick, have mental health conditions, are caregivers

Or because there are no jobs.

It will cause people to forgo doctor visits, and prevention /screening tests and not keep up with medications.

They will put off getting care until diseases are at more advanced, less treatable & more costly stage.

Lives are at stake: loss of coverage associated with thousands of preventable deaths.

This bill has to be stopped. Call Congress today. 2022243121. Urge them to vote against #AHCA. Don’t wait. Vote is on Thursday.

Trumpcare Facts:

The plan would hit older and rural Americans hardest because it wouldn’t provide a larger tax credit to people with more expensive plans.

The plan would reduce Medicaid spending by $880 billion, though Trump repeatedly promised no cuts to the program when battling his primary opponents.

Tucker Carlson raised this point with President Trump during a Fox News interview. “I know that, I know,” the president said, as the host cited Bloomberg’s finding that Trump-supporting counties would be hammered. “It’s very preliminary.”

“This isn’t consistent with the message of the last election,” Carlson said. “No, a lot of things aren’t consistent,” Trump acknowledged.

Eugene Robinson wrote a great article for PennLive about the myth of Republicans as the party of fiscal responsibility. The Republican Congress is pushing Trumpcare before the Congressional Budget Office has had a chance to estimate how much the measure will cost.

“It’s time to put an end to the myth that Republicans believe in fiscal responsibility. Saving taxpayer dollars takes a back seat to the ideological imperative of blaming and shaming the poor.”

“When you ask Republicans what they’re going to cut, they mention foreign aid — which totals about $35 billion, or slightly less than 1 percent of federal spending.

They threaten to eviscerate smaller agencies by cutting $6 billion here or $8 billion there — but at the same time, they applaud Trump’s pledge to increase the $600 billion defense budget by an incredible 10 percent.

They’re going to end up spending more — perhaps lots more — and collecting less in tax revenue. And this is the party that claims to care about deficits and debt?

But wait, Republicans say, we’re going to “save” the big entitlement programs by trimming benefits. Yeah, sure. I’m not holding my breath.

The problem is that Medicare and Social Security serve middle-class and upper-crust taxpayers, including many who share the GOP’s punish-the-poor belief system. If you think these ACA-focused town halls are hostile, just you wait.

The fact is that among recent administrations, at least, Democratic presidents have been the relative skinflints. Bill Clinton, you will recall, actually balanced the budget — and yes, he had help from Republicans in Congress.

Barack Obama spent heavily at first to save the economy, which was teetering on the edge of a dreadful abyss, but he ended up slashing the deficit in half and presiding over years of uninterrupted economic growth.

George W. Bush, on the other hand, fought hugely expensive wars in Afghanistan and Iraq without accounting for them in his budgets.

He also convinced Congress to expand Medicare to cover prescription drugs, which was compassionate but costly.

Trump promises to be even more of a big spender. Among other things, he promises a trillion-dollar program to renew the nation’s infrastructure. Imagine the Republican howling if Obama had suggested such a thing.

The GOP will surely persist in its sanctimony about balanced budgets, but no one should pay any attention. Republicans, we see what you’re doing.”

According to a report in Politico, the number of GOP governors who have “expressed strong support” for their party’s plan is exactly zero, while 15 have voiced varying concerns.  Republican governors object to Medicaid federal allotments to the states limited by a per capita cap. Unfortunately, Trumpcare has the spending cuts without the flexibility.

 As Health Affairs notes, AHCA may actually be more prescriptive than the status quo, micromanaging several types of beneficiaries the authors do not want to receive coverage (e.g., lottery winners, the undocumented, those with home equity over a certain amount), without some general grant of flexibility.

The sought-after flexibility isn’t there:

The combination of federal funding reductions and the retention of the program’s comprehensive legal requirements would, in effect, create a perfect storm for states. While it is possible that some of these requirements could be eased by the Trump Administration using its section 1115 waiver authority, section 1115 is actually a limited research and demonstration statute, not a tool for wholesale statutory re-design simply to create new state flexibility. Furthermore, certain Medicaid provisions, such as premium and cost-sharing rules, are by and large excluded from the scope of 1115.

The GOP governors have noticed this disrespect from the authors of AHCA:

“Flexibility” has become a buzzword among governors critical of the bill. Baker, Snyder, Arizona’s Doug Ducey, Tennessee’s Bill Haslam, Wisconsin’s Scott Walker and Nevada’s Brian Sandoval say there is work to be done on the bill to ensure it grants the states the flexibility they need.

“The plan that was released doesn’t reflect what the governors want, which is flexibility,” Ducey told a local radio station in Phoenix. “I want flexibility at the state level to improve our health care system, to make these reforms. This is still prescriptive from Washington, D.C.”

Meanwhile, the Republican governors of Ohio, Nevada, Michigan, and Arkansas jointly declared their opposition to the bill, in a letter to Mitch McConnell and Paul Ryan. Like the Senate moderates, John Kasich and company want to preserve the increased level of federal funding that Obamacare provides Medicaid recipients — and, if cutbacks are needed, to limit eligibility rather than reducing reimbursements.

In other words: The governors don’t want Paul Ryan to take away the free money that’s keeping their low-income residents insured and their hospitals paid.

While governors, obviously, won’t get a vote on the AHCA, Republican senators from expansion states are subject to similar pressures. And on Friday afternoon, Nevada’s Dean Heller said he stands with his governor.

MSNBC reported that Republicans are not defending the big tax cuts for insurance industry executives in Trumpcare.

In the White House briefing room last week, a reporter asked HHS Secretary Tom Price why the Republican health care plan “includes a tax break for insurance executives that make more than $500,000. You said this is about patients. Why is that tax break important for this legislation?”

The Republican cabinet secretary was incredulous. “I’m not aware of that,” Price responded.

The bill really isn’t that long. How the Secretary of Health and Human Services, who presumably read the bill, could be unaware of the provision is difficult to understand.

Around the same time, House Speaker Paul Ryan (R-Wis.) was asked why his reform blueprint includes “a big, fat tax break.” The Republican leader responded, simply, “Read the bill.”

We did read the bill. The Republican plan to replace Obamacare includes a tax break for insurance company executives making over $500,000 per year.

If you voted for Trump because you wanted to see insurance-company executives get a big tax break, this is, of course, great news. For everyone else, however, it’s not quite as impressive.

Other tax breaks in the new reform legislation as explained by Vox explained:

It’s reasonable … to ask what there is to like about the proposal. The main answer, for Republicans is Congress, is that it also contains $600 billion in tax cuts — tax cuts that would save the wealthiest 0.1 percent of Americans nearly $200,000 each in a single year, according to a batch of analyses released by the Joint Committee on Taxation on Tuesday.

The single biggest tax cut included in the bill is the repeal of the 3.8 percent tax the Affordable Care Act applied to capital gains, dividend, and interest income for families with $250,000 or more in income ($125,000 for singles).

Repealing that tax is a change that, by definition, only helps the rich, or at least the affluent.

At a certain level, this shouldn’t come as a surprise. When Democrats crafted the Affordable Care Act, they intended to distribute benefits and resources in a progressive direction: those at the top would pay more in taxes, while those in the middle and on the bottom would receive more in the form of health security.

Republicans intend to undo the economics of “Obamacare,” which necessarily means going in a regressive direction: giving people at the top big tax breaks, while taking benefits away from everyone else.

Why in the world would GOP officials champion a health care proposal that would take away coverage from millions, increase deductibles and premiums, and leave much of the country worse off? It’s probably because Republicans really like cutting taxes for rich people.

For those on the right, this is a feature of the American Health Care Act, not a bug.

The Republican healthcare plan could signal the beginning of the end for employer-based healthcare insurance, a perk that millions of Americans take for granted.

Roughly half of Americans were covered by employer-sponsored health plans in 2015, according to the Kaiser Family Foundation. But that could change, according to the Congressional Budget Office’s report on the GOP’s American Health Care Plan. According to the CBO estimates,  7 million of people will drop off the roles of employer-sponsored health insurance over the next decade because of Trumpcare.

The tax credits are regressive

Like the Affordable Care Act, the American Health Care Act offers tax credits to help people afford coverage on the individual market (for people who don’t get health insurance at work). But compared to Obamacare, the new tax credits — which are largely based on age rather than income — would be more generous to the middle class and wealthy and less generous for the poor.

The average tax credit for Americans earning less than $40,000 per year would go down. But for those making more than $40,000, tax credits would go up under the Trump plan. (A 60-year-old whose income is around the federal poverty line would see her tax credit cut from around $10,000 to $4,000, while a 27-year-old earning more than $75,000 would get a new $2,000 tax credit.)

The Kaiser Foundation’s Cynthia Cox put this into a chart:

View image on Twitter

View image on Twitter

How tax credits would change for #Obamacare enrollees under the just-released House Republican replacement plan #AmericanHealthCareAct

Wow.  Where to start.  There have been so many articles about how bad Trumpcare is for everyone except insurance companies and rich people.

Vox analyzed the net financial impact of the Republican bill on premiums, after tax credits, plus cost-sharing. “We estimate that the bill would increase costs for the average enrollee by $1,542, for the year, if the bill were in effect today. In 2020, the bill would increase costs for the average enrollee by $2,409.”

“In general, the impact of the Republican bill would be particularly severe for older individuals, ages 55 to 64. Their costs would increase by $5,269 if the bill went into effect today and by $6,971 in 2020. Individuals with income below 250 percent of the federal poverty line would see their costs increase by $2,945 today and by $4,061 in 2020.”

Buzzfeed reported that Trumpcare  includes a tax break for insurance company executives making over $500,000 per year.  The average compensation for top health insurance executives is in the millions. In 2014 the Institute for Policy Studies found that this cap generated $72 million in additional tax revenue.

Companies can generally deduct employee salaries as a business expense but in 2013 the Affordable Care Act capped the deductions on health insurance executive salaries at $500,000.

NPR had a sober article explaining why the Republican plan will not fix any of the current problems with health care coverage. NPR explains why the law will not increase coverage, provide the consumers more chocie, or lower health care costs.

As part of Obamacare, the federal government increased payroll taxes to help pay for the Medicare Trust Fund. That fund is used to reimburse hospitals when seniors come in and need treatment.

Trump’s bill does away with those new taxes. As a result, the Medicare Trust Fund would go broke about four years earlier than currently projected, in 2025 instead of 2029. This would either force hospitals to either swallow the costs themselves, turn away Medicare enrollees, or both. Here’s what the tax repeal would do to the trust fund, according to the Brookings Institution:

View image on Twitter

View image on Twitter

Repealing the ACA’s tax on high income households and hospitals would exhaust the Medicare Trust fund by 2024