The Obamacare Knot

This morning, during a small press conference in anticipation of his budget proposal, Donald Trump turned to the subject of Healthcare, and said a couple of curious things. First, he said, “It’s an unbelievably complex subject, nobody knew healthcare could be so complicated.” Then, he said that he had to do healthcare reform before tax reform “because we have to know what the healthcare is going to cost and – statutorily – that’s the way it is. So for those people who say, ‘Oh gee I wish we could do tax first,’ it just doesn’t work that way. I would like to do tax first.”

On the second comment, it’s important to know that there are no statutes that require a Congress work on health care before they work on tax reform. They are not in a bind on this. Republicans are working on health care reform first, because they want to work on health care first. That’s a choice they’ve made, and it’s a choice the Trump administration is going along with.
Regarding Trump’s first comment, that “nobody knew healthcare could be so complicated,” what he meant was that he himself did not know healthcare could be so complicated, because literally every person who has ever worked on health care reform understands that it’s a complex subject that entails a lot of unpleasant trade-offs and difficult choices. I think it’s unlikely Trump has really gotten deep into the weeds on health care policy, but he seems to be waking up to the reality that health care reform is hard, as his more recent comments on health care policy have been more guarded and restrained than they were even a month ago. In January, he vowed that everyone would be covered under his new plan, that it would cost less, and that the coverage would be better. On Friday, at CPAC, he made no such claims. He merely promised it would be less expensive and “better.”

Republicans have campaigned on repealing Obamacare since the bill was passed in 2010, and have taken every opportunity to declare it a disaster and a failure. Trump quickly took up the mantle of Obamacare repeal during the campaign, and while he seemed to know little about what Obamacare actually is, he was sure that it needed to go. After his election, it looked as if repeal would be one of the administration’s top priorities. Ten days before his inauguration, Trump put pressure on lawmakers to repeal the law and pass a replacement bill almost immediately.

A month into Trump’s Presidency, the timetable for repeal and replace has shifted dramatically. Trump has conceded that the process may take well into 2017, and possibly longer. I think this is a big problem for Republicans in general, and for Trump in particular. Congressional Republicans are equipping themselves for a long fight, and during this fight, they are going to have to fend off a lot of attacks. Normally, Republicans would look to the leader of their party to take on the brunt of their public advocacy, but Trump seems to me to be uniquely unfit for such a task. As he demonstrated throughout the campaign, and has demonstrated since becoming President, he has difficulty sticking to a set of talking points and he often makes promises without laying out a plan for how to keep them. More importantly, he seems to be severely under-informed on key policy issues.

One of Trump’s major liabilities as President is that he does not know very much on his own about issues relevant to the presidency. Even if we assume he knows a more than most about the deal-making and international trade, these issues cover only a small portion of what a president has to deal with. When you follow Trump’s statements, especially when he’s speaking extemporaneously, as he does during interviews or did during the debate, it becomes clear that his personal knowledge base is actually quite small. When it comes to healthcare policy, it is fine, in principle, if Trump would prefer to stay back and let Congress sort it out, but he is, for better or worse, the leader of his party, and he has personally made repealing and replacing Obamacare a major priority. Moreover, while he has given no indication that he cares to learn the relevant details within the healthcare debate, he has shown that he cares about the politics of healthcare reform. He does not seem content to let Paul Ryan and Mitch McConnell figure out how they’re going to repeal and replace (or repeal and delay or just repeal) Obamacare. He believes voters want to see Obamacare repealed, and he wants to take credit for doing it. He also believes that when people say they want Obamacare repealed, they think they should get something better in its place. And he believes that when people say they “better” they mean something that offers more to them personally for a lower cost. So, until recently, Trump often boasted that his healthcare plan was going to be terrific, that it was going to cover everybody and cost less. That sounds great, and it’s a very popular position, except that it bears no relation to what Republicans want to do with the healthcare system. Republicans in Congress want to reduce the Federal government’s role in healthcare by rolling back the Medicaid expansion offered to the states under Obamacare. They want to lower costs for some people by allowing insurers to charge older, sicker patients more for insurance. They want people to be able to buy into cheaper plans that offer less coverage. They want to repeal the individual mandate. And, importantly, they want to cut taxes for wealthier households that are helping to finance the subsidies offered to poorer Americans. They do not have a plan to cover everybody, because they don’t believe that’s the government’s job. They don’t want to expand Medicaid further or make the subsidies more generous. They don’t want to force insurers to offer more affordable preventative care, or to offer a public option that competes with private insurers.

The problem for Donald Trump, then, is to square his desire to be popular, to be seen as a fixer, with the reality that Republicans don’t have some terrific, uncontroversial plan waiting to be enacted. What they have is a plan that does reduce the Federal government’s role in healthcare, but one that does so at the expense of some very popular items. Trump appeared to believe that repealing Obamacare would be easy, and that replacing it with something better would also be easy. But if it were easy, Republicans would certainly have already repealed the law, and would be at least gearing up to replace it. Trump seems to have accepted that this process is going to take a long time. He appears not to have understood that, in political terms, it may cost him tremendously.

In some sense, this problem is mostly a congressional Republican problem. The issue is that many of the things Republicans don’t like about Obamacare are not what the public dislikes about Obamacare, and they don’t have a way of fixing those things. Trump could still become popular if Obamacare repeal never happened. The problem is, Republicans have campaigned for over half a decade on repealing Obamacare, and now they have full control of the government. And Trump, rather than being ambivalent on the issue, has been bullish on it. Not only that, but he keeps promising that Trumpcare, whatever it is, will be better, and that everyone will love it.

I don’t think this is trivial. I don’t have any data, but I would guess that the number of people who voted for Trump in part because he promised them better, more affordable health insurance is not zero. I would also guess that many voters who support repealing Obamacare believe that there’s a better, cheaper bill waiting to replace it. Trump himself has done nothing to temper this expectation, and I think it’s likely he and his party are judged by voters in part on how they deliver, or don’t deliver, on that promise.

I assumed when Trump won the election that Republicans would repeal Obamacare as soon as they could. Obviously, they haven’t, and it appears we’re gearing up for a long process in which Democrats will be able to hit Republicans again and again on a few bite-sized talking points that make the majority party look terrible. This is where Trump’s basic ignorance regarding healthcare policy will hurt him. He cannot mount a strong defense of what Republicans are doing; he doesn’t know what they’re doing. His idea of what a good replacement plan looks like does not align with their idea of what a good replacement plan looks like. If the fight over Obamacare goes, as Trump predicted recently, into 2018, then Republicans are going to have to take on a lot of attacks and a lot of negative coverage. As the leader of his party, Trump is the obvious person to lead the defense, but he is among the people least qualified to do so.

Trump would be smart to take some time to bone-up on Republican talking points, and to actually learn some things about healthcare policy. He has, for the moment, stopped making promises no Republican intends to keep, but it does not appear he has taken seriously the precarious position he and his party are in, and all the ways this process could go badly for them. Republicans have decided that their fate depends upon Trump being a successful president, but more and more it seems as if the opposite is true, at least in the short term. If Republicans sustain significant losses in 2018 (and lose the House, say), the Trump presidency may well stall out, because Trump is, at the moment, toxic to the Democratic base, and Democrats in Congress may just choose not to work with him on anything. For a supposed fixer and a man of action, such a development could do great harm to the way he is perceived among voters.

Repealing Obamacare isn’t dead, of course, and it’s still the most likely outcome, but it appears now that it’s going to be a fight, and possibly that it’s going to be a long one. If it is, it’s going to need someone to make the case that repealing the law is the right thing to do. Trump, for all his bravado, does not appear to be up to the task.

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