For as long as there has been an Affordable Care Act, there has been a desire, among Republicans, to repeal the Affordable Care Act and replace it with an alternative plan. As far as having something on which to campaign, this has served Republicans in good stead. Ranting about the need to repeal Obamacare has never gone out of style with the GOP base.
The problem has always been with the “replace” part of the equation. For years, the GOP effort to produce an alternate plan has been, to be charitable, a fits-and-starts affair. Since March 2009, the Republican answer to Obamacare has been a Schrödinger’s bill. Or as Jonathan Chait once put it, the Republican replacement plans “reside in a state of quasi-existence, and any attempt to summon them into existence will cause them to disappear.”
But now ― and perhaps to them unexpectedly ― congressional Republicans face the crisis of an incoming presidential administration that will sign their repeal-and-replace bills into law. Which means the zero hour has finally arrived, and Republicans must undertake the dread mission they’ve been putting off.
There are, however, complications inextricably bound to the whims and desires of Donald Trump, who sees the matter in vastly different terms and, more often than one would prefer, communicates his desires in brief Twitter outbursts. Where Republican lawmakers want to act in accordance with their conservative philosophies, Trump operates strictly from the perspective of someone who wants to be loved and acclaimed, and who has won a healthy share of this acclaim largely through his masterful command of the P.R. of the moment. At bottom, Trump craves good publicity, and he’s starting to see the upcoming health care fight as something that might deny him that pleasure.
Since Trump’s election, Republicans in Congress have been debating their options. Faced with the need to do something as quickly as possible, GOP leaders have endeavored to build consensus around a plan to “repeal and delay” ― a process by which the underlying funding for the Affordable Care Act would be scuttled, but the mechanics of the law would be left in place. Then, by backstopping hospitals against financial risk and bailing out insurers during the interregnum so that they continue serving their existing customers (and so that hundreds of news stories about people losing all or part of their coverage are staved off), Republicans would buy themselves some time to, you know, come up with the thing they’ve been promising to deliver for eight years.
But the path to consensus has been fraught, with GOP leadership unable to determine how long precisely to “delay” the replacement (periods as long as four years have been floated) and with a faction of GOP lawmakers vocally opposed to any delay at all. Additionally, one of the more interesting things about the repeal-and-delay plan is that the effort that would need to be undertaken to prevent a calamity of bad publicity would inadvertently do the job of shoring up the existing law at some of its weakest points. And that would sure be ironic, as Chait points out:
Republicans can certainly patch up the exchanges and keep them going during a transition period. All it would require is halting their relentless efforts to blow up the law and start trying to make it work. (“They want to pump money back in to the insurers without appearing like they’re giving them a handout or bailing them out,” one insurance lobbyist explains.) But if they do this, then they’ll have essentially proven that they can fix Obamacare. And if they can fix it, why would they let it expire? Especially when the deadline for the replacement approaches and, inevitably, Republicans have still failed to produce a replacement?
Last week, in a series of tweets, Trump alerted his Republican colleagues to the snare into which they were about to step. “Republicans must be careful in that the Dems own the failed ObamaCare disaster, with its poor coverage and massive premium increases...like the 116% hike in Arizona. Also, deductibles are so high that it is practically useless. Don’t let the Schumer clowns out of this web...massive increases of ObamaCare will take place this year and Dems are to blame for the mess,” Trump wrote. “It will fall of its own weight - be careful!”
This outburst mirrored a longer Wall Street Journal editorial that appeared at the end of December, but it took Trump’s amplifications to convince some Republicans to take these warnings to heart. As “Meet the Press” reported, Sen. Tom Cotton (R-Ark.) was urging a cautious approach a day later, saying, “I don’t think we can just repeal Obamacare and say we’re going to get the answer two years from now. ... When we repeal Obamacare, we need to have the solution in place.”
And Sen. Bob Corker (R-Tenn.) ― who apparently is among the fortunate few whose calls Trump will pick up whenever they come in ― is suddenly concerned that the GOP’s repeal-and-delay effort will land the Republican Party in a “box canyon,” which actually sounds pretty fun until you find out that “box canyon” is a strained metaphor for “being on the hook for an unexpected tax increase.” As Roll Call’s Niels Lesniewski reports:
Speaking at a breakfast hosted by the Christian Science Monitor, Corker outlined the potential “box canyon” that Republicans could find themselves in if they repeal all of the taxes imposed by the Affordable Care Act on the front end.
If there’s a need to further extend the existing subsidies for lower- income health care recipients beyond the three-year bridge under discussion or if the replacement plan features refundable tax credits down the road, “that means Republicans would have to vote for a tax increase.”
Corker said to the reporters in attendance that the result could be an extension of current policy driven as much by inertia as by anything else.
Lesniewski goes on to report that while Corker understood the “tremendous desire by Republicans to just repeal immediately,” he was more inclined to Trump’s point of view, and he “pointed to comments by Trump that said repeal and replace should be moved simultaneously.”
Days later, it became apparent that Trump’s anxieties were being felt widely among Republican legislators, with a “half-dozen” lawmakers “call[ing] publicly for slowing down the process.” As The Huffington Post reports:
“Repeal and replace should take place simultaneously, and this amendment will give the incoming administration more time to outline its priorities,” Sen. Bob Corker (R-Tenn.) said. “By exercising due diligence we can create a stable transition to an open health care marketplace that provides far greater choice and more affordable plans for the American people.”
And Corker, apparently getting a busy signal from Trump’s phone, was begging the incoming president to please send some clarifications. As Politico reports, Sen. Rand Paul (R-Ky.) let it be known that he had spoken to Trump earlier in the week and had “secured his agreement” to Paul’s demand that repeal and replace happen simultaneously. Trump hadn’t publicly confirmed this, leaving Corker with no other choice than to ask Trump if he would do so: “If it his view, it would be really good if he would consider tweeting it out very clearly.”
It seems insane that Republican lawmakers are begging Trump to tweet them instructions, as if they take their marching orders from an obscure numbers station. But the fact of the matter is that Republicans haven’t had an original thought on what to do about Obamacare in years. The threat of President Barack Obama’s veto pen has always protected them from the consequences of a repeal vote.
As far as replacement plans go, the same lawmakers have been stuck in an endless cycle of proposing bills (always with the same components ― health savings accounts, buying insurance across state lines, tort reform), sending those bills to committee to die, chafing at criticism that their alternative plan doesn’t exist, and rebooting the process anew. On this issue, congressional Republicans have always desperately wanted someone else to call the shots. They live to be led ― and the intermittent messages from Trump’s Twitter account is as good at filling that role as anything else.
But while Trump may have helped his Republican colleagues recognize the trap they were in, it’s anybody’s guess as to whether he can truly lead them out of it. Over the course of the presidential campaign, Trump offered up any number of opinions on what the state of American health care should ideally resemble, but those were restricted to vague principles and few specifics.
For example, in a September 2015 “60 Minutes” interview with Scott Pelley, Trump said that “everybody’s got to be covered” and that “the government’s gonna pay for it.” At a February 2016 GOP primary debate, Trump told the audience, “What I do say is, there will be a certain number of people that will be on the street dying and as a Republican, I don’t want that to happen. We’re going to take care of people that are dying on the street, because there will be a group of people that are not going to be able to even think in terms of private or anything else and we’re going to take care of those people.”
But at other times, Trump has scaled back those promises. In a post-election “60 Minutes” interview with Lesley Stahl, Trump offered that he’d continue to assure that people with pre-existing medical conditions were covered by insurance and to maintain the extended period through which children may remain on their parents’ health plans. Still, as recently as Jan. 3, Trump spokesperson Kellyanne Conway was, on his behalf, making a difficult-to-keep promise. As CNBC’s Dan Mangan reports:
One more time: If you like your plan, you can keep your plan.
“That is correct. We don’t want anyone who currently has insurance to not have insurance,” the advisor, Kellyanne Conway, said on MSNBC’s “Morning Joe.”
Perhaps Trump’s position is best summed up by a July interview with CNN, in which he said, “[Obamacare’s] gotta go. ... Repeal and replace with something terrific.”
The problem is that everyone has a different idea about what constitutes “terrific.” To Trump’s legislative partners, that means plans with high deductibles and threadbare benefits that mostly offer catastrophic coverage, subsidized by health savings accounts ― unless, of course, you or your employer are able to afford something better.
What would be terrific from the point of view of Trump voters? Well, in a New York Times op-ed last week, the Kaiser Family Foundation’s Drew Altman reported on a series of focus groups conducted with Rust Belt Trump voters who are either on Medicaid or enrolled in insurance plans through the Affordable Care Act. Their responses were very interesting.
Among their chief complaints were “rising premiums, deductibles, copays and drug costs,” as well as “surprise bills for services they believed were covered” and “hopelessly complex” plans. Those with Affordable Care Act plans “saw Medicaid as a much better deal ... and were resentful that people with incomes lower than theirs could get it.” Ideally, these focus groups said, their health care plan would “focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs.”
Of course, there has never been any indication that a Republican alternative to Obamacare would move in the voters’ preferred direction. Rather, any alternative plan would almost assuredly double-down on all the anxiety-inducing features of their current plans. As Altman noted, this would probably not go over well with those voters:
Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act — including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage — several of these Trump voters recoiled, calling such proposals “not insurance at all.” One of those plans has been proposed by Representative Tom Price, Mr. Trump’s nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.
When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called “chaos” if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, “a smart businessman like Trump would let that happen.”
This is, perhaps, the biggest disconnect between Trump’s voters and the people in whom they’ve placed their trust. Republican legislators are hoping to get a quick repeal and to buy some time to come up with a palatable plan ― but there’s never been any indication that they can stomach actually creating a plan that’s truly in line with what their constituents want. Trump sees a looming political trap and wants there to be a period of inertia so that Democrats end up taking the blame for entropy in the Affordable Care Act’s marketplace ― which is probably what a Republican-controlled Congress would have done if Hillary Clinton had won the election.
The problem is that Trump has styled himself as a different sort of president. Like that focus-group participant averred, Trump voters think they elected a “smart businessman” who won’t let bad things happen. He’s supposed to be a swashbuckling outsider who’ll start cutting through Washington’s thicket of idleness and start delivering better deals to the American people.
Trump may prefer that Democrats take further heat for Obamacare’s problems. But his voters don’t want this can to be kicked down the road any further, and they want the “terrific” replacement promised to them.
With all that in mind, it’s hard to see where Trump and GOP lawmakers go together, because it’s not clear they ultimately want the same thing.
Perhaps Trump will do something truly audacious: suggest that the GOP simply fix the Affordable Care Act, sell it as a repeal-and-replace job, and rebrand the whole thing “Trump Care.” Indeed, that canyon is only truly boxed if Trump ignores the exit pass, the one that leads to a health care system that people actually like.
It wouldn’t be in keeping with conservative philosophy, but that hasn’t stopped Trump before. Besides, if you look at the actual details of what Speaker Paul Ryan (R-Wis.) wants to replace Medicare with, it looks a lot like the Affordable Care Act. They could all take some form of spiteful pride in essentially stealing Obama’s landmark legislation from him ― which, I suppose, is fair turnabout, since Democrats originally stole it from the Heritage Foundation and Mitt Romney. You shouldn’t discount the extent to which animosity inside the Beltway is solely driven by who ends up getting to take credit for what.
And in this scenario, Trump could gain what he desires most: public affection. It would be a sordid and petty way to resolve this eight-year long conflict, but at long last, it would provide a way for everyone finally to “win.”
Jason Linkins edits “Eat The Press” for The Huffington Post and co-hosts the HuffPost Politics podcast “So, That Happened.” Subscribe here, and listen to the latest episode below.