Why Selling the Public on the AHCA Will Not Be Easy


Cheriss May/Sipa via AP Images

House Speaker Paul Ryan shakes hands with President Donald Trump upon the passage of legislation to roll back the Affordable Care Act in the Rose Garden of the White House.  

One of the foundational principles of Donald Trump's business career, one that he transferred over to politics, is to always act like you're winning whether you actually are or not. So it was that he and House Republicans gathered in the Rose Garden on Thursday to stage a giddy celebration of the passage of a bill through the House that most (if not all) of the assembled legislators hadn't read, that the Congressional Budget Office hadn't scored, that was dead on arrival in the Senate (where Republicans will start over to write a new bill), and that every sensible observer agreed was practically a political suicide pact.

You have to give them some credit for successfully passing this malignant tumor of a bill through the House; given his record as a legislative leader, I doubted Paul Ryan was capable of it. But no matter what legislative twists and turns await, the chances that they're going to be able to convince the public that the American Health Care Act (AHCA) is a great idea are somewhere between slim and none, even for a party that has shown itself unusually deft at propaganda.

The first thing they're up against is loss aversion, our natural tendency to fear potential losses of what we have more than we look forward to potential gains of something we don't yet possess. Loss aversion is the biggest reason why it's so difficult to win support for sweeping policy change, especially if you're taking away a benefit people enjoy and promising that things will be even better when you replace it with something else.

And the AHCA would subject people to extraordinary losses—tens of millions would likely lose their health coverage, and tens of millions more could lose protections the Affordable Care Act now provides. The potential gains, meanwhile, are utterly implausible; we're supposed to believe that what is largely a return to the status quo ante before the ACA passed will leave everyone better off.

Few believe that, which is why an earlier version of the AHCA got a whopping 17 percent support in one poll. And that was before Republicans went back and made the bill even more cruel by gutting protections for those with pre-existing conditions in an attempt to win the support of the ultra-right House Freedom Caucus.

The pre-existing conditions question has now come to the top of the health care debate, which makes things even more challenging for Republicans. The ACA's protection for those with pre-existing conditions may be the single most popular provision in the law, but here's how things will work under the Republican plan:

You'll have to start documenting your entire health history when you buy insurance (remember that?), and you'll be safe if you have a pre-existing condition as long as you don't experience a gap in your coverage, but if you do you'll have to pay a substantial penalty once you try to get insurance again, but you could be in trouble if you live in a state that has gotten a waiver to allow insurers to charge you impossibly high premiums, and you might be shunted into a high-risk pool, which given past experience will probably be underfunded and inordinately expensive, and offer substandard coverage.

Doesn't sound like such a great deal, does it? Now let's compare that to how things work right now for people with pre-existing conditions, who number somewhere between a third and half of all non-elderly Americans. Are you ready? Here it is:

You buy insurance. The insurer doesn't ask you about your health history, and can't charge you more because of it.

Republicans will be arguing, "No no, everything is going to be fine for people with pre-existing conditions when we make these changes! It's going to work great!" If they can convince Americans of that, they're far more skilled at PR than anyone understood.

Now think about how this debate is going to proceed in the immediate future. There's a reason they passed the AHCA before the Congressional Budget Office could evaluate the newest version. They saw what a public relations nightmare the CBO's score of the previous version was, with Democrats handed the priceless talking point that the bill would result in 24 million more Americans without insurance.

But guess what: The CBO is still going to score the bill they just passed. That score will be released this week or next week, and it's almost certainly going to be brutal. The news media will report extensively on this latest score, in all likelihood treating it—quite rightly—as an objective refutation of the bogus claims Republicans have been making about their bill. Don't be surprised if they struggle to even get 17 percent support for what they're doing now. Even if Republicans in the Senate come up with something slightly less horrific than what the House produced, the whole effort is going to be impossibly tainted by what has happened until now.

Watching all this, one couldn't help but be reminded of how, in 2010, Nancy Pelosi recited some of the ludicrous charges Republicans had made about the Affordable Care Act and said that "We have to pass the bill so that you can find out what is in it—away from the fog of the controversy." Republicans have cited the first part of her sentence ever since, as proof that the ACA was somehow hidden from the public and "rammed through" Congress before anybody knew what was happening. The truth, of course, is that there was no more extensively debated piece of legislation in recent history—a year of meetings and roundtables and hearings (79 in the House alone) and committee votes and amendments and floor speeches.

Nevertheless, Pelosi was half-right in her theory that once the bill became law, people would see its effects and it would become popular. Nearly all of the provisions themselves have enjoyed tremendous support—the expansion of Medicaid, the closing of Medicare's prescription drug "donut hole," the protections for people with pre-existing conditions, and young people being allowed to stay on their parent's insurance, among others. Where she was mistaken, as were most Democrats (and more than a few observers, myself included) was in the assumption that the popularity of the individual provisions would translate into popularity for the law as a whole.

That's because the "fog of controversy" never disappeared, a tribute to the success of Republican propaganda efforts to make the vague idea of "Obamacare" something toxic, even as the law accomplished a great deal. But now they're trying to pull off something much harder: they need to convince the public that a bill whose details are utterly grotesque is actually a great idea. At least Democrats had a potentially appealing product to sell.

Republicans don't, as most of them probably realize. But having come this far, they have to keep trying—at least until they realize the sales job has failed and it's time to give up. We haven't reached that point yet, but we may before long.

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