Editorial: Trump and Ryan are playing the long game with the Affordable Care Act repeal

Last week, the nation's hospital and physician groups joined patient, consumer and senior advocates in condemning the newly introduced American Health Care Act, which guts Medicaid and provides inadequate subsidies for buying individual health insurance plans.

Their concerns didn't faze President Donald Trump. Less than eight hours after those lobbyists hit “send” on their protest letters, he met with leaders of the radical right—the anti-tax Club for Growth, the Heritage Foundation (which in an earlier incarnation invented Obamacare) and the Koch brothers-backed Americans for Prosperity.

To win the votes of the three dozen or so members in the tea party-backed Freedom Caucus, who are calling the AHCA “Obamacare-lite,” the president needs to assure them that the final bill will be—from a provider, patient and consumer perspective—even worse. Without some Freedom Caucus votes, House Speaker Paul Ryan is unlikely to muster the 218 votes he needs to tack the AHCA onto a budget reconciliation bill.

Don't be fooled by predictions of some political analysts and pundits that the AHCA is “dead on arrival.” If Ryan needs to lurch further right to get it passed, he will.

Ryan has been around long enough to know that the final legislation will be hashed out in a conference committee since there's no way the Senate will pass the House version. Already, four Republican senators have come out against sunsetting Medicaid expansion payments in 2020 and shifting the program to capped per capita payments.

Can Senate Majority Leader Mitch McConnell, whose home state of Kentucky has been one of the biggest beneficiaries of the Affordable Care Act's insurance expansion, win over those waverers? He's going to have to come up with something a bit more generous than what's in the House bill.

The AHCA as presently written would all but destroy the individual insurance market as a place where low-wage workers can obtain affordable policies with meaningful coverage. Giving the uninsured $2,000 to $4,000 a year as a refundable tax credit will require those individuals to pay thousands of dollars more to buy a plan.

Even then, those plans will have much higher deductibles and cover fewer services than the worst plans under Obamacare. The bill also eliminates the subsidies for the less well-off to defray those out-of-pocket costs.

On the flip side, it will increase the subsidies going to middle-class workers since the tax credits don't begin phasing out until an individual earns $75,000 a year ($150,000 for a family). In other words, the legislation takes from the poor, gives some of that to the middle class and gives the rest to the well-off since it repeals the Obamacare tax hikes that extended Medicare payroll taxes to dividend and interest income.

And that is what lies at the heart of this “debate.” The majority party wants to cut entitlements so it can cut federal taxes. If they have any concern for the impact that undoing Obamacare and starving entitlement programs will have on health, it isn't apparent from their rhetoric about “choice” and “access.”

Trump and the Republicans are playing the long game. They're gambling that they'll be able to convince enough of their members to support a directional “repeal and partial replace” bill whose most draconian provisions won't go into effect until 2020. The final details will come after the 2018 mid-term election.

That will put tremendous pressure on Democrats, who will face a presidential veto no matter how they fare in the election, to go along with something as the 2020 deadline approaches. They won't want to see tens of millions of the nation's poorer citizens shut out entirely.

The AHCA is the starting point for this long-term Republican strategy. If successful in the next few weeks, it will put the nation firmly on a path toward a two-tiered healthcare system.

That violates the mission and ethos of every hospital and physician in America. The AHCA must be stopped now.