Republicans have a health care problem: what they want to do to the health care system is not popular. They think government should be minimally involved in health care, and that the fact that health insurance is too expensive for some is a problem that has been exacerbated by government involvement in the marketplace. They believe that the problems with the health care system can be solved with market-based solutions and minimal regulation. Most people, though, would prefer more government involvement in health care if it meant heightened security. Most people aren’t attached to a particular theory about how involved government should be in something if it works out for them. Republicans believe that, eventually, their ideas about health care will lead to greater security, but for many of them, that security is little more than an incidental effect. What is important to most Republicans is the idea that government does a poorer job than market forces at most everything. They want government out of the health care system. They understand, or most of them do anyways, that this will lead to many people losing their health insurance, or being able to afford only lower-quality insurance, because under the current system, many people are able to afford quality insurance only with some help from the government.
Most Republican politicians are not forthcoming about this. Republican policy wonks often are, but they have a limited audience. GOP politicians, who do have a larger audience, more often just lie. That may sound like an unfair characterization, but it’s what they’ve been doing. For seven years, they have complained, essentially, that Obamacare is a failure because it is not generous enough. Deductibles are too high, co-pays are too high, premiums are too high. Many people remain unable to afford coverage. Etc. Those are all reasonable qualms to have with the Affordable Care Act (ACA). Anybody who looks honestly at the law can see its glaring flaws. Obamacare has so far mostly failed to control costs, and many people do remain uninsured. Having heard Republicans talk about the law for the last seven years, one might assume they had been working on bills designed to fix those problems. They haven’t been, though. One might assume that the bill that just came out of the House is the culmination of seven years worth of careful thought about how to fix Obamacare’s maladies. It’s not. One could be forgiven for thinking that the bill that just came out of the House bore any connection to the shortcomings of Obamacare or put forward some way to fix them. The fact is, though, it doesn’t.
On process, too, there is a large gap between what Republicans have been saying and what they have actually done. Republicans charged Democrats with jamming Obamacare down the American people’s throats on party lines without seeking or allowing the kind of robust debate and negotiation such an important bill, on such an important issue, merits. One might assume, having heard Republicans talk about the process by which Obamacare was passed, that they would commit themselves to a different path. They haven’t. Instead, the House is poised to vote soon on a bill nobody knew existed until very recently. The bill, so far, has no amendments, has not been debated on the House floor, has not been scored by the Congressional Budget Office (CBO), and, according to Senate Majority Leader Mitch McConnell, will go straight to the Senate floor after passing the House.
This bill is not the result of rigorous debate, hard-won compromise, or careful thought about the problem it has ostensibly been brought forth to solve. Republicans are not taking the problem seriously. They are not acting as if this is a pressing national issue that deserves a robust solution.
Republicans have laid out problems that they aren’t attempting to solve. They have said this is a serious issue, but have addressed it in an unserious way. There’s a simple reason for this. They don’t believe the things they have been saying about health care for seven years. Republicans have made an effective case that Obamacare has serious defects, but they don’t actually believe it’s their job to fix them. The fault with Obamacare, in the minds of establishment Republicans, is that it created or expanded entitlements through its subsidies and Medicaid expansion. They believe it was wrong to raise taxes on rich people in order to fund these entitlements. They resolve this matter by cutting taxes on rich people, making the subsidies less generous, and sunsetting the Medicaid expansion. Doing those things doesn’t make health insurance more affordable for most people. It doesn’t lower deductibles or co-pays. It doesn’t expand coverage. It doesn’t do those things because it wasn’t designed to do them. It was designed, instead, to solve the “problem” of the government subsidizing poor people’s health insurance through higher taxation on wealthy people.
I assume Donald Trump doesn’t understand any of this. If he did, he would understand just how out-of-step this plan is with the way he has been talking about health care since 2015. He has said multiple times that he would not touch Medicaid, that deductibles would be lower under his plan, that premiums would go down, and that the health insurance offered to people would be much better. He even said, though hardly anyone took it seriously, that under his plan, everybody would be covered. He has now thrown his weight behind a plan that doesn’t even pretend to do those things. Now, Trump isn’t a particularly truthful fellow; he spent his business career lying to people and getting away with it, and his political career has been no different. That said, I think Trump probably talked about health care the way he did, because he intuitively thinks about health care policy the way most people do. In most people’s minds, covering more people is a good thing; lowering costs to consumers is a good thing; making insurance more affordable to the poor is a good thing. He has not shown any penchant for thinking about how to make those things happen, or even a desire to know how other people who have thought about it would go about crafting a solution, but I find it difficult to believe Trump really is in lock-step with congressional Republicans on this issue. I think he, like the American people, is being hoodwinked. He seems to think that this bill will lead to more Americans having better health care, and he thinks that because it’s what establishment Republicans have been telling him. They don’t believe it, though, and anyone who takes even a cursory look at this bill will see that it is just a first step towards eliminating the assistance Obamacare gave to poor people. Trump didn’t campaign on eliminating assistance to poor people. He made a direct appeal to the working poor that he would make their lives better. If he signs this bill, though, he will be making it harder for many of them to afford health insurance.
It would be smart for President Trump to take the time to learn about what’s in this bill, and to spend some time thinking about how it aligns with his campaign rhetoric. The bill repeals Obamacare (in a way), but it does not replace it with something “far better.” It replaces it with a tax cut for rich people, and less generous benefits for poor people. If he were to do those things, he may still decide to press on with it, thinking either that it’s better than nothing or that it’s just part of the deal he made with Republicans in which he gets to be odious and corrupt as long as he gives them their agenda. Then again, he might decide that he doesn’t like being lied to, that he doesn’t like letting other people control his agenda, and that he likes being perceived as a great deal maker who delivers on his gaudy promises, in which case, he would tell Republicans to stop messing around and send him something serious, that seriously addresses the flaws of Obamacare and seriously attempts to fix them.
We have no reason to believe President Trump will change course. He’s not going to read up the bill, because he’s not interested. He’s not going to reconsider the deal he made with Republicans, because keeping promises is not important to him. Most of all, he’s not going to reflect on the ways in which the bill may fall short of certain moral standards, because whether something is right or wrong rarely seems to cross his mind.