Misconceptions have dominated the debate over Republican legislation to reform Obamacare. The press has spread those misconceptions, and Republicans have done almost nothing to dispel them. That’s not the only reason Republicans have so far proven unsuccessful in enacting health-care legislation. It’s probably not even the most important one. But it is a big one, and Republicans still don’t seem to understand it.
The first misconception is about how many people would “lose” their health insurance under the Republican legislation. The House bill would supposedly “take away” insurance from 23 million people; the bill the Senate considered over the last few weeks would supposedly take it away from 22 million; and the “skinny bill” would take it away from 16 million in one year. No charge was made more frequently by Democrats against the bill. The press frequently repeated it and rarely challenged it.
But it wasn’t true. Under each of these bills, most of the reductions in coverage were driven by the voluntary decisions of people to go without insurance once they were no longer threatened with fines if they made that choice. The Congressional Budget Office report on the skinny bill implies that about 14 million people would leave the insurance rolls for that reason once the bill was enacted. An additional million or so would leave the rolls because the departure of those 14 million would send premiums higher.
There are, of course, arguments that people should be aggressively encouraged to buy health insurance: that they are better off that way, that their failure to do so inconveniences others (including those who would end up paying higher premiums), and so on.
Anyone following this debate, though, would have easily concluded that Republicans were taking desperately wanted insurance away from 14 to 23 million people.
Even if you believed the CBO’s estimates, that wasn’t right. Each of these bills would have left most of those millions of people, from their own perspective, ahead. (And it also would have made the people who have been paying fines better off.)
Other consequential misconceptions concerned Medicaid. Outlet after outlet reported that the Senate bill would “roll back,” “end,” or “phase out” Obamacare’s expansion of that program, that it cut hundreds of billions of dollars in federal spending on it, and that it threw millions of people off it. These claims, all of them significantly mistaken, got mixed up with the allegedly draconian caps in the legislation. “The Senate bill would end the Affordable Care Act’s expansion of Medicaid to millions of low-income Americans,” according to a typical account at a respected website (Vox, in this case). The most natural reading of that passage: Obamacare expanded Medicaid to cover millions of people, and the Republicans would undo the whole expansion.
Before Obamacare, Medicaid had covered people making less than the poverty line. Obamacare had expanded eligibility to people making up to 38 percent above the line. If states chose to cover these people, the federal government would pay nearly all the costs. The Republican bill did not undo this expansion of eligibility, as a straightforward repeal of Obamacare would have done. It did not end all payments for the newly eligible population, as did a 2015 bill that all Senate Republicans supported. Instead it reduced the federal share of the cost to the pre-Obamacare level. The federal government would still cover more than half the cost for people making up to 38 percent above the poverty line.
The Congressional Budget Office estimated that as a result of this change in the federal match rate, no further states would expand Medicaid to people above the poverty line. Some states that had expanded it would, supposedly, undo that expansion, even though their budgets would see less than 50 cents in savings for every dollar of benefits they cut for people in their states. Essentially all of the CBO’s projection about the shrinkage of Medicaid — in terms of both federal spending and of enrollment — was the result of a) the states’ response to the reduced federal match rate and b) the end of the fines for not getting insurance.
Whether the Republican proposals on Medicaid were wise is, again and of course, something about which people can argue. But a lot of people were left with the impression that the Republicans were kicking millions of people off Medicaid in some much more direct and certain sense than the GOP legislation actually involved.
And Republicans did almost nothing to counter this impression. In a well-run, coordinated campaign for a health-care bill, they would have challenged each and every news story that said Republicans were taking away insurance from 14 million-plus people, or that talked about coverage-change numbers while burying the role of voluntary decisions in driving them. They would have prodded reporters to do fact-checks when Democrats said Republicans would “kick tens of millions off insurance,” instead of just relaying Democrats’ misinformation. Republican press secretaries would have called the outlets that said they were rolling back the Medicaid expansion and walked the reporters through why they were wrong.
Nothing like that happened this time. A few Republicans made the point about voluntary departures from the insurance rolls — but only sporadically, rarely with numbers, never in a sustained way. A few Republicans tried to argue that they were slowing the growth of Medicaid instead of cutting it; Senator Toomey tried to make the point that the legislation wouldn’t by itself kick anyone off the program. But nobody took it as his job to sell the Medicaid reforms and challenge negative or exaggerated portrayals of them.
There was a more organized and disciplined effort on the part of Republicans to explain and defend their health-policy changes in 1995 and 2011, when they were seeking to reform Medicare, than there was over the last few months. And on those previous two occasions, Republicans did not have control of the executive branch. They did a worse job this time even while having that control.
There was no effort to persuade and defend in part because nobody owned these pieces of legislation. They were leadership products that had no particular sponsors.
There was no effort to persuade and defend in part because nobody owned these pieces of legislation. They were leadership products that had no particular sponsors. It didn’t happen because of the speed of the process. The CBO numbers that made it possible to tease out the effects of ending the fines on coverage weren’t available until the day the Senate voted on the skinny bill, which was itself only produced that day. Republicans probably thought that speed would help them pass something, but instead it contributed to an atmosphere of hyperbole and hysteria.
Conservative health experts couldn’t have done the Republicans’ communications job if they had wanted to. And they mostly didn’t want to: They had not been seriously consulted in the design of any of this legislation and they had their own complaints about it. So they, too, didn’t do much to defend it.
I don’t believe that congressional Republicans must or should give up on making major changes to Obamacare. They may even decide that another try, as much as they dread the idea, beats the alternatives. If they do, consider my points above a suggestion for what they should do differently next time. If they don’t, add it to the pile of explanations for why they failed.