Let us imagine that you would like to redistribute hundreds of billions of dollars from working class people to the rich, and wouldn’t hesitate to risk the lives of tens of thousands of people to do so. Well, as luck would have it, there is a bill— the “American Health Care Act” (AHCA)—that does precisely that.

On Thursday, it squeezed through the House of Representatives. Trumpcare – at least for the moment – has been triumphant.

Many of us thought – or hoped – that Paul Ryan’s bill was as good as dead on 24 March, when, in a pleasurable political moment (a rare event these days), he admitted he lacked the votes to push it through. But where there is a will to degrade the healthcare safety net, there is a way. And, to the House Republicans’ credit, they indeed found a way to ram this grotesquerie through.

Republican healthcare bill heads to Senate, where it may undergo drastic changes Read more

To do so, the hard right had to compromise with the harder right, which made the current version of the AHCA fouler than the original.



The harder right found much to like about the original bill – like its historic gouging of Medicaid. The problem was that it left too much of the regulatory infrastructure of the Affordable Care Act (ACA) intact. Rules that insurers must cover 10 “essential health benefits” and cannot discriminate against those with pre-existing conditions? Eliminate those provisions, and let healthcare freedom reign.



The compromises worked. First, there was the MacArthur amendment, which permits states to redefine “essential health benefits” (this would allow insurers to exclude coverage of some types of healthcare, such as maternity care), or to allow insurers to charge people with pre-existing conditions higher premiums if they failed to maintain coverage.



As Timothy Jost noted on the Health Affairs blog, the latter provision “could effectively make coverage completely unaffordable to people with pre-existing conditions”, notwithstanding the clearly inadequate high-risk pools.

So far, so good.



However, in appeasing the harder right, the House leadership risked estranging the less hard right. But the latter proved to be a cheap date: they were bought off by the Upton amendment, added at the eleventh hour, which gave another $8bn to the fund theoretically designed to cover those left behind by the AHCA. Though this was a drop in the bucket relative to the size of the problem created by the AHCA, it brought just enough moderates back on board to secure a winning vote.

If the AHCA were signed into law by Trump – an unlikely but not impossible proposition given the headwinds it faces in the Senate – the negative impact on ordinary Americans would be enormous.



Given that the House GOP didn’t bother to wait for the Congressional Budget Office (CBO) score before voting, we don’t know just how bad it will be. But relying on the CBO’s initial estimates, we can say that the AHCA will, over a decade, reduce spending on Medicaid alone by more than $800bn.



Together with savings from having less adequate, skimpier insurance subsidies, these reductions will allow hundreds of billions of dollars to be channeled to the wealthy and corporations in the form of tax cuts.

By enriching the rich in this manner, the AHCA would leave an estimated 24 million more uninsured by 2028. Similar calculations have already been done, but it’s worth briefly revisiting the blood-arithmetic on this.



Colleagues of mine recently reported estimates, in the American Journal of Public Health, of how many newly insured people there would have to be to prevent one death per year. These estimates, which, being estimates, aren’t perfect, were based on five studies. The numbers ranged from 300 to 1,239 people.



If we were to pick a round number on the conservative end of that range – say 1,000 – we would estimate that stripping insurance from 24 million people would produce an estimated 24,000 additional deaths annually. That is 66% more than the sum total of all murders, estimated by the FBI at 14,429 for 2014 (using somewhat different numbers, Vox’s Julia Belluz makes this point and comes to the same figure).

Now, in all fairness to House Republicans, as a critical care physician, I too get blood on my hands when I go to work. The only difference is I can wash mine off.



Modern medicine saves lives, while stripping healthcare coverage from millions to fund tax breaks for millionaires takes lives. There’s no way around it, whatever some may tell themselves to help them sleep at night.

This, of course, raises an even larger issue, namely the injustices of the healthcare status quo, wherein 28 million remain uninsured and even more without adequate coverage – shortcomings that leave open the door to continued attack from the right.



This execrable, homicidal bill must obviously be stopped. But that’s not all we must do. The most enduring defense against the rightwing saboteurs is not continued championship of a flawed status quo, but instead the promise of a better tomorrow: healthcare for all, through a single-payer universal system. That alone will put an end to these deadly assaults on healthcare.

