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Conservatives’ Excuses for Kicking Millions Off of Health Care Don’t Make Any Sense

Debunking the right's three main justifications for Trumpcare.

Drew Angerer / Getty Images

There is no single story conservatives can tell to brush aside the fact that the House and Senate GOP health plans will throw tens of millions of people off of their health plans.

The magnitude of the coverage loss under both bills is too large to be explained away with any single tendentious argument. Conservatives have thus taken to deploying multiple, mutually contradictory arguments to dispute, or blunt the political impact of, analyses showing GOP health care legislation will add 20-plus million Americans to the ranks of the uninsured, relative to current law.

This somewhat embarrassing trend wouldn’t be necessary if more conservatives had enough faith in their own convictions to admit they believe taxation of the super wealthy to subsidize health insurance for the poor and working class is one injustice compounding another.

Instead, they offer these three justifications for not rejecting Trumpcare out of hand.

The Congressional Budget Office is wrong.

There are weak and strong versions of this argument, the former of which takes issue with the CBO’s track record, the latter of which takes issue with its methods. The former, favored by Trump administration officials, is more easily digestible, but more obviously deceptive. The latter, favored by conservative writers, has at least some merit, but nowhere near enough to sand the rough edges off of Trumpcare.

Trump and GOP officials contend that the CBO, for all its accounting prowess, is very bad at economic modeling. Which is why they allegedly bungled their impact analyses of the Affordable Care Act, and why their impact estimates of Trumpcare should be discarded, at least with respect to its coverage loss forecasts.

This petty and demoralizing attack on the aptitude of the CBO’s staff economists is the preferred spin of Health and Human Services Secretary Tom Price, Office of Management and Budget Director Mick Mulvaney, White House spokespeople and others. It’s also nonsense.

The CBO, of course, didn’t know when they completed its initial work on the ACA that the Supreme Court would allow states to opt out of the law’s Medicaid expansion. So its early scores of the law read strangely in hindsight. But the main thrust of the Trump administration critique is that the CBO predicted more people would be buying plans in state-based insurance exchanges than they are today. This is true—but all it proves is that the CBO was wrong about which health care systems (the small-group market, the employer-sponsored insurance market, etc.) the newly insured under Obamacare would be distributed between.

Their estimates of how many people would gain insurance under the law have been spot on.

Of course, this crew of critics is also fond of saying that Obamacare is collapsing, in spite of several CBO assurances that it is not, so their antipathy is in some sense a kind of natural enmity between liars and people who strive for accuracy.

A number of conservatives outside the official party apparatus has put forth the subtler claim that the CBO overrates the incentive effects of the individual mandate. If true, it would imply the CBO had overestimated the expected coverage loss under Trumpcare.

Unfortunately, there’s no reason to think this is true, and even if it were true—indeed, even if the individual mandate had no incentive effect at all—the bulk of coverage loss CBO anticipates is attributable to massive GOP-proposed Medicaid cuts. Even if CBO adopted assumptions about the mandate that were as friendly as possible to Republicans, these conservatives would still be left to defend kicking more than 10 million people off of their health plans.

The Congressional Budget Office is right—about freedom.

This argument is more popular among congressional Republicans and this one guy at National Review. As House Speaker Paul Ryan told Fox News, “What they’re basically saying at the Congressional Budget Office is that, if you’re not going to force people to buy Obamacare, if you’re not going to force people to buy something they don’t want, then they won’t buy it.”

This is … not what the CBO said. But even if it were, it would be equivalent to saying Republicans want to unleash the power of the market which will produce plans that 20-plus million people will decide are garbage. This is not what these Republicans intend to be conveying, but it is consistent with their final excuse for the horrible Trumpcare CBO scores.

Insurance is stupid anyhow (for you).

This is a critique conservatives apply only to Medicaid, because to extend it to private insurance—the kind of insurance conservative policy wonks have, and would not voluntarily part with—would reveal its hollowness and insincerity.

The purpose here is to devalue the kind of insurance most people will lose under Trumpcare. The method is to ignore the bulk of scholarship on the impact insurance has on health outcomes in order to hyperfocus an Oregon study which was too underpowered to detect an effect on mortality, but did find that Medicaid populations are financially and psychologically better off than comparable populations who have been denied Medicaid.

Avik Roy, who has been on a P.R. offensive for a bill he refuses to say whether he helped to write, falsely describes Medicaid as “a program that researchers have shown has health outcomes no better than being uninsured.”

I would wager that zero conservative pundits would voluntarily surrender their health plans, even if those plans provided them only financial and psychological security. I would also wager that zero of those pundits would refuse to enroll their families in Medicaid were they to become unexpectedly impoverished.

What they will happily do is try to convince other families that their insurance is worthless, and convince the government to take huge risks with those families’ livelihoods, on the presumption that they will never be poor or uninsured themselves.