“Nobody knew health care could be so complicated.”
That was President Donald Trump speaking at the White House Monday, and if anything can encapsulate the dilemma facing Republicans as they haltingly try to keep their campaign promises to repeal and “replace” the Affordable Care Act ― aka Obamacare ― it’s that.
The idea that “nobody” knew health care is complicated is, of course, nonsense ― as literally anyone who’s ever visited a doctor or used health insurance could tell you. But the realization seems to have come belatedly to Trump.
Perhaps Trump will use his address before a joint session of Congress Tuesday to lay out a detailed plan for how to remake the health care system. But the president’s own shifting and contradictory statements about health care reform suggest that he remains unclear about what to do and how much ownership to take of the consequences of repealing the Affordable Care Act.
At a recent meeting with Ohio Gov. John Kasich (R), for example, Trump seemed to be swayed by appeals to keep much of the law’s coverage expansion in place. The governor drew charts on pieces of paper on the president’s desk outlining the potential costs of repeal, an aide familiar with the exchange told The Huffington Post.
“He responded very positively to a number of the ideas I had,” Kasich, who used the Affordable Care Act to expand Medicaid, said on CBS News’ “Face the Nation” Sunday.
Trump went over the charts three separate times, and even got his newly installed Health and Human Services Secretary Tom Price on the phone to discuss it further, according to the aide. Other aides had to remind the president that the congressional Republican plans are far less generous, after which Trump expressed preference for Kasich’s approach, as The Washington Post reported.
At a separate meeting with a bipartisan group of governors, meanwhile, Trump largely punted on details for his health care plan when pressed by attendees, a source familiar with the session who was not authorized to speak publicly about it told HuffPost. But when Price said that there would be a replacement plan in place about four weeks after repeal was enacted, Trump did chime in, saying it needed to be done in two or three weeks.
House Speaker Paul Ryan (R-Wis.) and Senate Majority Leader Mitch McConnell (R-Ky.) seem to have a better sense of where they want to go with repeal ― perhaps because they, especially Ryan, have spent more time focusing on the issue.
But these congressional leaders haven’t been able to bridge the divides in their own skittish caucuses about the timing or scope of the repeal and “replace” effort. Meanwhile, there has been a groundswell of anger over the prospect of killing the increasingly popular law.
Ryan appears desperate enough to advance Affordable Care Act repeal that he’s considering pushing legislation to the floor and essentially daring reluctant and unsatisfied members to vote against it, The Wall Street Journal reports.
The bet is that few Republicans would pass up a chance to damage the Affordable Care Act, lest their supporters see them breaking their promise to do so. This trial balloon didn’t soar long: On Monday, Rep. Mark Meadows (R-N.C.), who chairs the conservative House Freedom Caucus, said that he would vote against a forthcoming GOP leadership proposal if, like a version that leaked to Politico last week, it still had elements of an entitlement program.
That underscores Republicans’ risky bid. Additionally, legislators would have to be on record calling for millions of people to lose health care with no guarantee that the Senate would follow suit, or that Congress as a whole would eventually come up with something better than the Affordable Care Act.
This disarray is new ― although, in hindsight, it was to be expected. In the years since Democrats in Congress and then-President Barack Obama began putting together the Affordable Care Act and working to implement it, Republicans have had the luxury of sitting in the backseat, criticizing the law and talking about how much better they could do.
Now they’re in the driver’s seat, and they can’t even agree on a destination, much less a route to get there.
Republicans are trying to square their promises to, as Trump put it, offer “great health care” that’s “much less expensive and much better” while still eliminating the taxes on wealthy people and health care companies.
That’s pretty much impossible, because those taxes pay for about half of what the Affordable Care Act does ― and there’s no enthusiasm for alternative ways to raise the money.
Republicans also can’t square their promises of great health care with the party’s ideological commitment to smaller government, since without regulations, insurers will offer policies that cover fewer services and offer even less financial protection. And without generous government subsidies, poor people and many middle-class people won’t have enough money to buy coverage.
That draft legislation that leaked to Politico makes clear how leaders intend to resolve the inconsistencies in their rhetoric. They would weaken protections for people with pre-existing conditions and dramatically slash federal spending on health care for the poor and the middle class, while proposing a new tax on the job-based health benefit plans that cover the majority of Americans.
The result would be many more people without insurance and much greater exposure to medical bills for those who have coverage, according to an analysis of the plan that Axios and Vox obtained.
This approach isn’t surprising. Ryan’s philosophical idol is the “objectivist” writer Ayn Rand, and he believes that high taxation of the wealthy is morally wrong and that the government should provide far less help to the indigent than it currently does. McConnell has a more flexible ideology, but he’s never had much of an appetite for preserving big government programs when he can kill them instead.
The White House, though, is another story. Trump certainly isn’t an orthodox conservative, and he’s barely a Republican in the traditional sense.
On the one hand, Trump chose Price, an ideological conservative, to be secretary of health and human services. And at various points during his candidacy and the presidential transition, he embraced reforms consistent with Ryan’s.
On the other hand, Trump also keeps pledging “insurance for everybody,” a pledge utterly inconsistent with Ryan’s and Price’s proposals, and with decades of GOP health care policies.
The simplest explanation for the inconsistency is ignorance ― Trump doesn’t really understand the trade-offs of health policy, and can’t be bothered to learn. His comment at the White House Monday supports that theory.
But it’s also possible that Trump has genuinely mixed feelings. The abstract notion of snatching away health coverage from millions of poor and working-class families may not trouble the president’s sleep, but some of those folks are his voters, and they’re growing increasingly worried that when Republicans promised to repeal Obamacare, it meant their Obamacare, too.
We also know that Trump’s advisers are divided, as The Washington Post reported over the weekend.
Vice President Mike Pence and others are urging the president to forge ahead with repeal. But chief strategist Steve Bannon, senior policy adviser Stephen Miller, presidential son-in-law Jared Kushner (whose brother runs a health insurance company) and National Economic Council Chairman Gary Cohn don’t want the president mired in the health care mess, according to the report.
This is the dawning realization that repeal is politically riskier than GOP lawmakers allowed themselves to acknowledge during the past eight years.
The health care fight is also sucking up time and political capital, creating higher hurdles for Trump and the GOP to advance the rest of their agenda, including tax cuts for the rich and infrastructure spending.
The question is whether at some point Trump decides to steer this debate in one direction or the other. He may not. He may just remain hands-off, or continue to send conflicting signals. But at some point the fate of reform may hang on his actions ― whether it’s giving up, lobbying legislators or, ultimately, signing a bill. In other words, he can’t duck the choice forever.
And so it will be interesting to see whether, on Tuesday night, Trump decides to start weighing in more forcefully. Like the man said: It’s complicated.
Sam Stein contributed reporting.
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