The American Health Care Act, which passed in the House last week, is a cornucopia of Republican hypocrisies. Republicans claimed the problem with Obamacare was that premiums were too high and government subsidies to purchase insurance too low, but their replacement would allow insurers to charge older and sicker people higher premiums, while providing substantially less financial assistance to pay them. Republicans have been whining for years that Obamacare's passage was rushed (though it was debated for seven months), but they passed their slapped-together bill without holding a single hearing, just weeks after introducing it. And after howling that the Obamacare process lacked transparency, House Republicans not only voted on Trumpcare without waiting for a CBO score estimating what it will cost and how many people will lose insurance – they voted without even making the full text of the bill public.
But nothing illustrates the Trumpcare Republicans' willingness to abandon the principles they claim to hold so dear quite like what the bill does to women's health care. Let's set aside the fact that the party whose official platform advocates making abortion a crime just voted to allow insurers not to cover maternity care and to allow states to give fewer pregnant women and children Medicaid. Republican advocacy for policies preventing women from ending pregnancies but against policies protecting the health and economic stability of women who wish to bring their pregnancies to term may be the height of hypocrisy – but it's old news.
There is a less obvious truth about Republican values exposed by the Trumpcare provisions concerning women's health care: Their commitment to free markets and federalism is a farce.
Obamacare upended the status quo of insurers assuming the male body to be the default, and treating normal health care for women as something exotic to be had at extra charge. Obamacare forbids charging women higher premiums than men, and mandates that certain essential services be covered.
But anti-Obamacare Republicans reject the idea that individuals should have to pay into a system that covers services they may not ever need – that is, they reject the basic premise of insurance – or much of any role for government in making sure citizens have health care. Instead, they favor the idea that we should let insurers competing in the markets decide what services are covered, or at least let states rather than the federal government determine what the coverage requirements are.
So Trumpcare allows states to seek waivers to free insurers from various Obamacare requirements, including those mandating coverage for essential health services. The criteria for qualifying for a waiver are quite loose, so we can expect Trump's HHS Secretary Tom Price to give one to every state that asks, regardless of whether they take any meaningful steps to offset the harm to patients. That means women in red states who don't have employer plans that are more comprehensive than required or qualify for Medicaid will have to either anticipate getting pregnant and pay higher premiums, or pay many thousands of dollars out of pocket. The message from Republicans is that they must stop federal regulation to protect women's health in order to vindicate the sacred federalist principle of state control and the free-market notion that if consumers want quality products, they can pay more for them.
But within the very same bill, Republicans demonstrate what fair-weather freemarketers and federalists they are. Despite their opposition to regulations protecting health services for women, they are happy to interfere in order to stop states from requiring insurers to cover abortion and to keep insurers from covering it voluntarily.
Trumpcare would replace the Obamacare subsidies that moderate-income purchasers of individual health plans currently receive with much smaller tax credits of $2,000 to $4,000. Those already meager tax credits would not be available to anyone whose health plan covers abortion, which, for instance, includes everyone in the states of New York and California.
GOP Rep. Dan Donovan raised this issue before last week's House vote, explaining he couldn't support a bill that denied everyone in his state tax credits. But his fellow House Republicans blew him off. As a spokeswoman for the House Ways and Means Committee put it, "it will be incumbent on states to adapt as federal law changes." In other words, Republicans want to force states to change their laws in order to prevent women from being able to afford abortion services.
That strategy requires a complete reversal of the "states' rights" argument Republicans used to get a portion of Obamacare struck down by the Supreme Court. Obamacare opponents argued that Obamacare's Medicaid expansion, which originally required states to expand their Medicaid programs with federal funds or lose all Medicaid funding, was unconstitutionally coercive. That argument was a bit of a stretch at the time, because the Court had generally allowed the federal government to put conditions on the funding it provides to states. But the Obamacare opponents won, strengthening the legal precedent that prevents the federal government from commandeering the states to implement its policies.
That anti-Obamacare ruling is the basis of a recent court decision blocking Trump's anti-sanctuary city executive order, and would also likely underpin any decision striking down the provision of Trumpcare depriving individuals with abortion coverage of tax credits. California's health insurance commissioner, who is running for attorney general, has said he would sue if the de facto abortion coverage ban went into effect – and because courts aren't anywhere as quick as Republicans to abandon principles they have recently upheld, California would likely win.
Republicans' willingness to meddle with markets and state laws to prevent women from accessing reproductive health care is part of a larger pattern. Anti-regulation zealots like Sens. Ted Cruz and Mike Lee are all in favor of regulating abortion clinics out of existence. Purported supporters of patient choice voted to bar Medicaid patients from receiving any kind of health care at Planned Parenthood. And numerous red states already prohibit private insurers from covering abortion.
The bottom line from Republicans is this: They won't regulate to guarantee women access to health care, but they're happy to use regulation as a weapon to deprive them of care that states or free markets would otherwise provide.