Republicans Didn’t Understand Obamacare’s Problems—Or How to Fix Them

And just like that, it was over.

On Friday, House Republicans pulled their proposed replacement for the Affordable Care Act (commonly known as Obamacare) from consideration. Seven years of alarmist rhetoric over a law some elected Republicans considered the downfall of the republic came to nothing. It’s a good thing, too. The Republican replacement plan was a profoundly broken piece of legislation that misunderstood the ACA’s real problems, bungled their solutions, and continued a pattern of duplicity that ran through the entire repeal effort.

Since the ACA’s passage, Republicans have repeatedly stated that their goal in repealing it was to save families from poor-quality, expensive care. They emphasized that some beneficiaries of the ACA were experiencing high premiums and deductibles. While these were legitimate problems under the law, they weren’t solved in the Republican replacement bill. In fact, it’s hard to imagine how they could have been solved under the framework Republicans adopted, as many of their proposed changes to the ACA would have made the situation worse.

One of the stranger changes Republicans wanted to make had to do with the Affordable Care Act’s metal rating system for insurance. Under the ACA, there are four main types of plans on the individual market: bronze, silver, gold, and platinum. These distinctions are made on the basis of actuarial value (the percentage of cost paid by the insurance company). A bronze plan covers 60% of costs, silver 70%, gold 80%, and platinum 90%. Deductibles decrease as the actuarial values increase, while premiums rise. These limits do raise the cost of insurance, as individuals are required to purchase a minimum amount of coverage, but they also guarantee that all those insured have meaningful protection in the event of a healthcare emergency.

The Republican bill eliminated these actuarial value minimums, theoretically allowing insurance companies to devise plans that only provided a modicum of protection. While these plans would offer incredibly low premiums, they would also have incredibly high deductibles. In other words, those on these plans would technically have health insurance but would pay dearly if they wanted to actually use it. This could hardly be considered an improvement.

This strategy–of increasing access by offering worse coverage–was also evident in the bill’s proposed changes to the Affordable Care Act’s essential benefits provisions. The ACA defines ten “essential benefits” that every plan on the marketplace must provide. These include prescription drug coverage, mental health services, preventative care, and hospitalization. While the initial draft of the Republican plan kept all ten of these benefits, the final bill allowed for states to define their own set to mandate. This change would have allowed for insurance plans that didn’t cover expensive anti-cancer medication, or, perhaps even worse, surgery.

A charitable view of these provisions is that they were intended to introduce more choice into the marketplace, lowering prices through competition and allowing consumers to purchase plans they wanted, rather than ones the government told them they should want. However, the parts of the Affordable Care Act that are working best involve more government, not less. The Medicaid expansion–an opt-in program that gave substantial federal money to states willing to enroll households at up to 133% of the federal poverty line–has proved to be quite successful. In states that expanded Medicaid, the number of people enrolled in the program increased by 37.78% over the period from September 2013 to November 2016, as opposed to the 13.89% increase in states that didn’t. Expecialy when compared to the more qualified success of the exchanges, the Medicaid expansion is a powerful endorsement of simple, government-guaranteed health coverage.

The success of the Medicaid expansion didn’t protect it from congressional Republicans, however. Their repeal bill reduced Medicaid funding to pre-ACA levels by 2020, though those who had already gotten coverage under the ACA would be allowed to keep it. It also included a provision that allowed states to receive their Medicaid funding as a block grant rather than on a per-capita basis. This block grant would give states significantly more discretion in how their Medicaid funds were spent. Effectively, block-granting Medicaid would represent a deep cut to the program, all but eliminating the entitlement to coverage.

This is the crux of the issue. Congressional Republicans’ fundamental objection to the Affordable Care Act isn’t high premiums or low-quality care. Instead, it’s that they view the law as a profound governmental overreach. They are repulsed by those things that have a real chance of fixing the ACA’s problems and improving access to care, like adding a public option or increasing subsidies. Instead, they chose to double down on a market-based approach that had proved ineffective in the past and had even experienced difficulties under the ACA. Their bill would have worsened the situation it claimed to improve, and Americans are lucky it failed.