Poorer and older Americans would come out worse. So would those living deep in Trump country

PITY the poor Republicans. For the past four nationwide American elections, their rallying cry has been the outright repeal of the Affordable Care Act, better known as Obamacare. Now, with nearly complete control of government in the party’s hands, the promise has come due. Tonight, the House of Representatives is scheduled to vote on their plan to overhaul Obamacare and replace it with the American Health Care Act (AHCA). As would be expected of a Republican bill, the AHCA would reduce the amount of money redistributed via the health-care system from the rich to the poor, leaving lower-income Americans with less assistance. More surprisingly, it would also benefit the young, who lean towards the Democrats, at the expense of the middle-aged, who tend to support Republicans—and might aid voters who backed Hillary Clinton while harming those who made Donald Trump president.

As a candidate, Mr Trump promised that “everybody’s going to be taken care of” by his replacement of Obamacare with “something terrific”. That vow is hard to reconcile with an analysis by the Tax Policy Centre, a think-tank, of the AHCA’s impact. It found that all American families making less than $50,000 a year would be worse off financially if the bill became law. Those earning less than $10,000 a year would be hit the hardest, losing $1,420 a year, or an average of one-third of their incomes. On the other hand, the AHCA’s tax cuts would put an extra $5,600 a year in the pockets of families making more than $200,000.

ACHA Older Americans would also suffer under the proposed new system. Today, 60-year-olds making $50,000 generally spend 10-15% of their income on health insurance. If the AHCA passes, many would pay several times that. In Alaska, premiums for some seniors would rise to a ludicrous 69% of income, according to modelled estimates from the Kaiser Family Foundation, a health-care think-tank. The consequences would be direst in counties that backed Mr Trump overwhelmingly in last year’s election, putting Republican representatives in a difficult position. In La Paz County, Arizona, where 72% voted to “make America great again”, poor seniors could expect the cost of health insurance premiums after taxes to rise from 5% of their incomes under Obamacare to 132% under the AHCA.

The bill will have to surmount steep political obstacles to become law. Wonks from the Congressional Budget Office dealt it a harsh blow last week when they released a forecast that by 2026 the AHCA would increase the number of Americans without health insurance by 24m, gifting Democrats with a useful cudgel. Because of concerns about maintaining insurance coverage and affordability, numerous moderate Republican legislators have come out against the bill. Meanwhile, the hard-line House Freedom Caucus opposes it for not going far enough to dismantle the architecture of Obamacare. Rand Paul, a libertarian senator, has dismissed it as “Obamacare-lite”. Combined with unanimous opposition from Democrats, this brewing revolt could bring an embarrassing defeat for Paul Ryan, the speaker of the House and architect of the AHCA.

ACHA

Still, House Republicans are hoping to quash dissent within their ranks, by making just enough modifications to the bill for it to pass by their self-imposed deadline. Mr Ryan has been steadfastly working the backbenches, and, in a closed-door meeting, Mr Trump threatened to “come after” one particularly unruly congressman. Millions of Americans’ health care will hinge on their powers of persuasion.

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