Trumpcare Takeaway: Stakeholders Matter

The main lesson we should take away from the failure of “Trumpcare” (or “Ryancare”) is the importance of stakeholders. When groups representing every type of stakeholder (medical professionals, hospitals, patients, and insurers) all came out against the American Health Care Act, its fate was pretty much sealed.

By now I think everyone can agree that the American Health Care Act (AHCA) was never intended as serious legislation. The utter failure of GOP lawmakers to consult with stakeholders, not just in the past two months, but at any point during the last seven years, made it clear from the beginning that they were not really interested in replacing the Affordable Care Act (ACA) with a real healthcare plan, so much as a political “win.”

In contrast, before voting on the ACA, Democrats spent nearly a year holding hearings, listening to experts, and getting buy-in from stakeholders (doctors, patients, hospitals, insurers).

RIP Trumpcare2

The Republican leadership’s bypassing of the legislative process not only shows disregard for the people they purport to represent, but it also reveals just how little many members of Congress know (or care) about basic economics, much less healthcare economics. After listening to hours of “debate” over the past few weeks, I’ve come to the conclusion that most Republican House members (and probably some Democrats) don’t have the first clue how our health insurance system actually works, much less how changing it might effect their constituents.

Contrary to Republican nostalgia, I don’t think most Americans want to move backwards. The ACA protections (no exclusion for pre-existing conditions, essential health services, no lifetime caps, yearly out-of-pocket maximums) are the new standard. No amount of extolling the “free market” and “freedom to chose” will convince people they are better off without these ACA protections. In fact, the more protections Republican leadership gave away, to try and win over the Freedom Caucus, the more they spooked moderates in their party who feared the political repercussions of taking healthcare away from their constituents. And rightly so. By Thursday only 17% of the public supported the AHCA. By cancelling the vote numerous Republican members of the House were saved from voting against the interest of their own constituents.

Over the past few weeks Republicans couched their opposition to the ACA in terms of “freedom.” What they failed to recognize is that yes, Americans want freedom—the freedom to not worry about how they’re going to pay for healthcare.

Infographics Part II: ACA Medicaid Expansion vs. AHCA Per Capita Caps


Medicaid beneficiaries stand to lose the most under the American Health Care Act (AHCA). According to the new Congressional Budget Office Report, Medicaid recipients would make up a disproportionately large share of 24 million people expected to lose health insurance coverage by 2026 if the GOP legislation becomes law.

Under the Affordable Care Act (ACA) 32 states expanded Medicaid eligibility to low-income adults earning up to 138 percent of the poverty line (about $34,000 for a family of four). The AHCA, as currently written, continues expansion for three more years before cutting federal funding to state Medicare programs through a per capita cap, limiting coverage to those enrolled before 2020. Vox recently provided a good explanation of per capita caps as does the Kaiser Family Foundation.


Many of the best Medicaid infographics predate the release of the AHCA, but they still remain relevant to the current discussion. The KFF website includes a large collection of data on Medicaid expansion, including maps (like the image above) and detailed Medicaid State Fact Sheets.

The Center on Budget and Policy Priorities (CBPP) produced the following charts estimating the costs to states of the per capita cap.

Medicaid Cost Shift CBPP

MEdiciad Cuts Growth OVer Time CBPPCBPP also created a series of fact sheets illustrating the effects of Medicaid cuts in nine different states. Here is the fact sheet for Pennsylvania:

PA Fact Sheet CBPP.jpg

Images in the slideshow below appear in The New York Times article “Republicans’ Changes to Medicaid Could Have Larger Impact Than Their Changes to Obamacare”

This slideshow requires JavaScript.

See Part I: Tax Credits vs. Premium Subsidies

Coming Soon:

Part III: Individual Mandate vs. Penalty for Break in Coverage

Part IV: Cost Comparisons