Trump Deserves Much of the Blame on Health Care
President Trump has used some of his vacation time to criticize Senate Majority Leader Mitch McConnell for signaling that he plans to move on to tax reform in September rather than make another attempt at repealing and replacing the Affordable Care Act (ACA).
There is certainly plenty of blame to go around for the GOP’s failure to pass a meaningful health care bill before the August recess, but most of the finger pointing should be directed at Trump, not McConnell.
The president seems to think he needs only to pressure Congress to fulfill the long-standing Republican campaign commitment to repeal and replace the ACA. He has made it clear he doesn’t care what’s in the legislation as long as it can be called Obamacare repeal and replacement.
But the primary obstacle to achieving that goal is disunity among Republicans over how to replace the ACA. Even if the president doesn’t care what’s in the bill, many millions of Americans do care, which means their Representatives and Senators need to care as well. Instead of building consensus, Trump has deepened divisions with an erratic mix of conflicting signals, general disinterest about the subject matter, and an utter unfamiliarity with the critical details of health policy that can make or break reform legislation.
At various points during the campaign and since his inauguration, Trump has promised to provide a plan for reform that would “take care of everybody.” Seven months into his time in office, his administration has still not produced anything resembling a coherent plan to replace the ACA. Further, he described the House-passed version of repeal and replace, the American Health Care Act (AHCA), as a “great plan” in May, only to call it “mean” in June as the bill came under assault from critics.
At no point during the campaign or since the inauguration has Trump articulated any kind of clear vision for how to improve health care. There is no unifying theme around his pronouncements, such as the promotion of a market-driven system. Instead, he makes vague statements about how the ACA is a disaster, without specifying with facts what he means with his criticisms, and then promises that he will deliver a better plan without describing in any way exactly how he will do it.
There is a sense among some Republicans that they were oh-so-close to getting the job done, despite Trump’s unhelpful zigzagging, when Sen. McConnell cobbled together his last resort “skinny repeal” amendment, which only failed to pass in the Senate when John McCain voted against it. But the skinny repeal amendment was an admission of failure, not a sign of progress. It was an eight-page amendment that didn’t repeal the ACA, or replace it. The amendment included no changes to Medicaid, and had only a very modest delay in the law’s taxes (on medical devices). The only provision of consequence was the elimination of the penalties associated with the individual mandate, which would make the individual insurance market less stable by allowing more healthy people to exit it without penalty.
Republicans worked hard to convince themselves that passing an embarrassing bill like the skinny repeal plan through the Senate was a good idea because it would bring them one step closer to achieving their goal of enacting something into law. But it was never explained by any of the key Republicans involved how a conference of House and Senate GOP members would be able to produce something better than the very inadequate plan that was the final product of two full months of intense deliberations in the Senate.
Because of the difficulty of assembling a coherent and workable replacement for the ACA, some Republicans would like to abandon the replacement effort and pass a repeal-only bill. At various points in recent weeks, Trump has signaled support for this approach too, which has created even more confusion and division in Congress. While some in the GOP like this idea, it will never pass in Congress because it would create too much anxiety among the many millions of people who get subsidized insurance under the ACA.
Immediately after passage of the ACA, in March 2010, then-House Speaker John Boehner released a statement pledging that Republicans would pursue a repeal and replacement of the law. That formulation was no accident. Boehner and most other Republicans at the time understood that going back to the pre-ACA status quo was not an option because it was a dysfunctional system that needed to change. And so the GOP’s commitment was to repeal and replace the ACA with something better; a repeal-only bill does not fulfill that commitment. Republicans in Congress believed in 2010 that the ACA wasn’t the answer, but most of them knew then, and still know now, that something needed to be done to lower costs and to make insurance more widely available.
Unfortunately, seven years after the enactment of the ACA, Republicans in Congress and in the Trump administration still don’t have a clear vision for what they would do differently from the ACA. That is why their effort to roll back the law has foundered.
Instead of pushing McConnell to pass whatever can get 50 Republican votes in the Senate, Trump and his aides should regroup and do the hard work that should have been done months and even years ago to come up with a more plausible approach to health reform. The goal should be to develop a plan built more on market principles than on government control and regulation, and which can garner support from most Republicans, and some Democrats too. Such a plan would necessarily be more incremental than a plan written just by GOP members, and it would roll back less of the ACA than many Republicans would like to see occur. But it would also be far less controversial than the various versions of repeal and replace that have been assembled so far this year, and thus also more likely to survive when political control inevitably shifts again.