A republican health care bill in search of a problem

Republican leaders in the House have been huddling over the last few days in a frantic search for enough votes to win passage of their proposed revision of Obamacare, in the process making an already flawed bill even worse. One measure of their desperation was a cynical last-minute provision that would shift Medicaid costs from New York’s rural and suburban counties to the state government, pleasing upstate Republicans who represent those counties but reducing coverage provided by the state.

Such wheeling and dealing has done nothing to improve a bill that would rip coverage from 24 million people over 10 years, leaving more Americans uninsured than if Congress simply repealed the Affordable Care Act, and inspiring an official of the American College of Physicians, which represents 148,000 doctors and medical students, to say on Monday that he had “never seen a bill that will do more harm to health.”

It also reflects a fundamental reality: Unlike President Barack Obama, whose clear objective was to expand access to medical care, the Republicans have no coherent idea or shared vision of what they want to achieve and what problem they mean to solve.

Do they want to cover nearly as many as are covered under the A.C.A.? A few senators, like Susan Collins of Maine and Bill Cassidy of Louisiana, say they do, but a majority from the party are not willing to spend the money that would be needed to do that. Or do they want to significantly reduce government spending and regulation of health care, leaving Americans to navigate the free market on their own? Conservatives like Senator Rand Paul of Kentucky and Representative Mark Meadows of North Carolina are arguing for that, but the rest of the congressional Republicans do not want to go down this treacherous path.

In place of a common vision is a truly unappetising stew. Modest subsidies to help people buy insurance are the Mini-Me versions of Obamacare policies, so reduced as to be almost completely useless to millions of people, especially older and lower-income people and those in states with high medical costs, such as Alaska, North Carolina and Oklahoma — all of which happen to have voted for Mr. Trump. Another provision is an old conservative hobby horse championed by people like House Speaker Paul Ryan: cutting federal spending on Medicaid, which provides insurance to 74 million poor, disabled and elderly Americans. The main goal here is to cut taxes for the rich, even though the change would devastate beneficiaries, state government budgets and public hospitals.

The bottom line: The Republican proposal would not increase “competition and consumer choice” as Mr. Ryan claims. It certainly wouldn’t deliver on President Trump’s promise of “insurance for everybody.” And it wouldn’t be the full repeal of the A.C.A., or Obamacare, that many Republicans have been promising their base for the last seven years. That is why some hard-liners say they will oppose the new bill, which the House is expected to vote on as early as Thursday.

In a better world, this bill would never have seen the light of day, much less be offered for a vote. It is no fair-minded person’s vision of what the American health care system should look like. It is designed to let Mr. Ryan and Mr. Trump declare that they have driven a stake through the heart of Obamacare, no matter the collateral damage to millions of Americans.