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It's difficult to underestimate the relief provided by the Affordable Care Act to American cities and their mayors. Mayors, after all, hear about local health issues from everyone-from first responders and uninsured constituents to doctors and hospital executives. As the mayors see it, Obamacare has reduced the numbers of uninsured people using hospital emergency rooms, provided the benefits of 21st-century medicine to people who never had access to it, and created thousands of jobs in metropolitan regions.

Unlike Republican members of Congress, mayors do not have luxury of fighting ideological cage matches with politicians of different persuasions until they can cudgel them into submission with an ill-advised, hastily crafted bill to replace reforms pulled together by a Democratic African American president. If Obamacare had been McCaincare or Romneycare the Sequel, the nation would be engaged in a different conversation.

Mayors, on the other hand, have to get stuff done, so facing down angry constituents in town meetings and compromising with political opponents is hard-wired into their daily existence. In a late February U.S. Conference of Mayors press conference phone call with reporters, New Orleans's Mitch Landrieu laid out the likely consequences of the Republicans' "repeal and reform" handiwork.

"The message to the states and the people," he said, "is you are on your own."

Like most mayors, Landrieu, the vice president of the U.S. Conference of Mayors, preferred a fix-and-repair strategy to deal with ACA flaws, including preservation of the Medicaid expansion that provided uninsured people with insurance and allowed health-care providers to expand programs in areas like mental health and substance abuse.

"Without a suitable replacement [we are] going to feel this at all local levels," said Boston Mayor Marty Walsh, who was also on the call.

According to Landrieu, Medicaid expansion funds support more than 50 New Orleans primary health-care clinics. More than 350,000 people have secured access to health insurance in the last year, after Louisiana expanded Medicaid.

In Boston, there has been a similar multiplier effect. Area teaching hospitals have received about $23 billion in federal funding, Walsh said. Losing those dollars would put jobs and research programs at risk. Hundreds of thousands of people in both states stand to lose coverage under the current Republican plan.

Most mayors are immersed in the finer details of budget-making and want to know what the fiscal and economic ramifications of any federal proposal are, especially one that is a major departure from previous policies. With House Republicans unwilling to wait for the Congressional Budget Office to weigh in on costs, it is not surprising that the U.S. Conference of Mayors has castigated the bill's lack of transparency on its costs and the number of people it would cover.

Where President Trump sees a proposal that "will end with a beautiful picture," the U.S. Conference of Mayors sees a plan that is "bad for cities, bad for people who live in cities and bad for people who provide healthcare in cities." But while some of the nation's Republican governors have been vocal opponents of the House plan and have likely moved the needle in the Senate, there are fewer Republican mayors who can exert comparable leverage.

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The 2016 Menino Survey of Mayors found that that city leaders have developed a "partisan immunity" to many of the polarizing issues like immigration, race, health care, and poverty that too many members of Congress view as having only one correct answer-theirs.

Poverty is a problem of titanic dimensions for cities, and a national health-care policy that backpedals on Obamacare's support for coverage for the poor bodes ill for the health-care and economic challenges that mayors confront daily.

Congressional Republicans view any number of historically federal programs, most particularly health-care financing for the poor, as a state prerogative, one they argue gives patients more control over their own medical choices. Mayors, by contrast, see health care as a basic human right, not a privilege to be granted or denied depending on the whims of members of Congress or state lawmakers. Local officials fear returning to the time when poor people were compelled to rely on emergency room doctors to treat such routine ailments as flu in adults and ear infections in toddlers.

Under Speaker Paul Ryan's proposal to kill Medicaid as a guarantee of coverage to the poor, federal health dollars would flow instead into state capitals, subjecting the allocation of those funds to the kind of intrastate political wheeling and dealing that may not mesh with better health-care outcomes for residents. Even if states are controlled by progressives, the level of funding the feds would provide would be sharply reduced from those provided under the ACA.

"Everybody knows that when you give [funding] to governors, they have to parse it around the state based mostly on politics and not necessarily on science and health care," Landrieu said. Without substantial revisions to the Republican plan, mayors will find themselves hemmed in between Washington's intransigence and their state's own political turf wars.