WASHINGTON ― As the dust settles from Friday’s collapse of “Trumpcare” in the House of Representatives and fingers try to point out the various losers, at least one clear winner has emerged: facts.
As in: the realities of the health insurance market, and their resistance to conform to promises made on the campaign trail.
In 2009, President Barack Obama was criticized for failing to schmooze lawmakers sufficiently ― for being an imperious technocrat when the situation called for a glad-handing salesman.
Eight years later, Republicans had precisely that in President Donald Trump ― a self-described dealmaker who neither knew nor cared about the details of health care, but who promised a “terrific” plan to replace “the disaster” of Obamacare by dint of his personality alone.
After fast-tracking a proposal to repeal the Affordable Care Act as the first major legislative item on the agenda of a unified, all-Republican government, Trump and House speaker Paul Ryan pulled their “American Health Care Act” just minutes before a scheduled vote. Too many Republicans ― dozens, both conservative Freedom Caucus members as well as moderates ― were prepared to vote against it.
“That is the growing pains of being a governing party,” Ryan said later.
Trump, characteristically, blamed Democrats for not supporting him and declined to discuss any specifics in his own legislation. Asked about what lessons he learned from the episode, Trump answered: “We learned a lot about loyalty. And we learned a lot about the vote-getting process.”
But Trump’s and Ryan’s problems go beyond whipping votes among fellow Republicans. Because for all the bashing Republicans have given the Affordable Care Act as government overreach and “socialized medicine,” Obama’s signature health care law was built upon a Republican, market-based foundation.
Its core principles were dreamed up in a conservative think tank in the 1990s as a way to counter the far more sweeping health-care plan pushed by President Bill Clinton. A version of it was implemented a decade later in Massachusetts under Republican Gov. Mitt Romney.
This, in fact, was the reason so many liberal Democrats were infuriated with Obama in 2009 for proposing a GOP plan to start with, rather than a single-payer scheme like they preferred. Obama, having started with a plan he believed Republicans should have been eager to support, grew frustrated when GOP leaders instead decided to oppose it unanimously and characterize it as a typical liberal entitlement.
Yet Obama’s negotiating strategy, or lack of one, notwithstanding, the ACA in the end was designed to deliver health care using the existing model of private insurance using government subsidies for premiums. The much-derided “individual mandate” to purchase health insurance would not have been necessary had Democrats gone with a “Medicare for all” proposal, but was crucial under the ACA to hold down premiums by spreading the costs of serious illnesses across a wider base.
Republicans who have claimed for seven years that they could replace the law with something that would eliminate the mandate yet cost less and provide better health care ― Trump went so far as to promise coverage to everyone ― are quickly getting a lesson in reality.
Chief among them: Trump himself, who explained something new he had learned ― that making one change in one part of the law has consequences in other parts of the law. “Nobody knew that health care could be so complicated,” Trump said last month.
When House Republicans and Health and Human Services Secretary Tom Price came up with their plan, the non-partisan Congressional Budget Office found that it would cause 26 million to lose insurance compared to the ACA, with premiums skyrocketing particularly for the elderly just below the eligibility age for Medicare.
Several rounds of tweaks designed to pull in factions of unhappy Republicans later, House Speaker Paul Ryan was on the brink of forcing the members of his majority to vote on legislation that would let states eliminate “essential health benefits” from policies. That move to assuage his most conservative members was not at all palatable to moderates worried about their constituents ― that is, voters ― losing coverage entirely.
In other words: When the unaccountable language of political campaigns ran up into the facts of the real world, the facts won. At least for now.