Deal or No Deal? No Deal…. This Time. But More Will Come

“Obamacare is the law of the land. … We’re going to be living with Obamacare for the foreseeable future.”  — Speaker of the House Paul Ryan (R-WI) on 24 March 2017

The last ten days of the Donald Trump Administration has had more drama and newsworthy events than any recent presidency in memory.  Most of it was not good news.  Not good for the country and not good for the Trump Administration.  Ranging from the revelation that the FBI is conducting a long-term investigation into ties between the Trump campaign and foreign entities, to the failure of the House of Representatives to vote on a replacement for the Affordable Care Act (ACA). The American Health Care Act (AHCA) was pulled by Speaker Ryan because of its sure defeat in the House.  A defeat I may add, that came despite the fact that the Republicans had a majority in the House of Representatives, the Senate, and the White House.

There are many reasons why the bill failed, and I am sure that pundits will dissect those reasons at length as time goes by.  Among the most prominent in my view, is that as the final push began to go from theory to an actual bill, the Republicans lost sight of policy and focused primarily on politics. In so doing they ended up changing the bill in ways that left only 17% of Americans in favor of it replacing the ACA.

Despite President Trump’s promise on 17 January 2017 that his health care bill was nearly finished and would be revealed shortly, he apparently did not have one of his own and went with the proposal crafted by Speaker Ryan.  In that January interview, President Trump also insisted that his health care bill would provide “insurance for everybody” and that people “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”  Which, surprisingly from this administration, turned out not to be true.

One could also ask why after seven years of campaigning on “repeal and replace” the Republicans did not have a viable plan, worked on by all factions of their party, with the contentious issues litigated before hand, ready to go?  It became a lesson for the new majority that opposition is much easier than leadership.

Speaking of leading, President Trump learned that leading the nation and a divided government is much different, and I would add more difficult, than running Trump, Inc.  The “closer” couldn’t close and he found that threats to an equal branch of government do not carry much water when the president’s approval rating is only in the 30’s and his disapproval rating is in the high 50’s.

There are other significant issues at play and we will see how things work out in the coming months as the president moves on to more “fun” (his word) endeavors such as tax reform and infrastructure renewal.  However, I think that all concerned are naive to believe that health care is resolved for the future.  In many ways, this is just round one of a longer, continuing saga.  As always, the devil is in the details and there are many details yet to be resolved before the battle of the ACA vs. AHCA is over.

Recall that President Trump and others continually repeat that the ACA is a “disaster” and in his usual method of communicating complicated issues, tweeted that “ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!”  One of many such tweets where he constantly reiterates that ObamaCare (the ACA) will “explode” or “implode” depending on his mood of the day, and blaming everyone — Republicans, Democrats, bureaucrats, a long list — for the failure of the bill to pass the House.  He blames everyone but himself or his dogmatic but very inexperienced staff, even as insiders say that he never really understood the policy behind the bill, nor really had much interest in it other than as a tag line during the campaign.

“Nobody knew that health care could be so complicated.” — President Trump on 27 February 2017

Here is the real point.  In fact, President Trump and his administration can turn his prediction into a self-fulfilling prophecy.  By regulatory action, or inaction, and by refusing to defend or promote the current system, they can indeed cause it to fail.  Not tomorrow, not the next day, but over time they can ensure that it fails without the proper attention to implementing its provisions.

Nearly all impartial adjudicators, including the Congressional Budget Office, state that under current provisions, the ACA will not explode, implode, or otherwise become a disaster.  It is working. However, it is not working perfectly and could use improvement.  In particular the number of insurance companies participating are decreasing, and deductibles in some areas are increasing. There is some debate as to whether this is happening because of the uncertainty that surrounded the ACA leading into the introduction of the AHCA or other factors.  Generally, the experts say that this trend can be reversed and in any case, does not impact all Americans.

The ACA — ObamaCare if you will — can be improved and should be improved.  Just like Social Security and other programs, the original plans are rarely perfect and it is entirely reasonable to see changes that improve the process and benefits.  Hopefully, now that the histrionics from both parties are over, the real leaders of the House and Senate can sit down in a bipartisan way and work on fixing the things that need to be fixed in the ACA.  I am not optimistic that it will happen. It will be difficult because from a policy viewpoint it is expensive and from a political viewpoint the Republican majority cannot pass such legislation without significant numbers of Democrats on board.  Thus far they have shown themselves to be unbelievably reluctant to pass anything that needs Democrats to carry the day. Conversely, at this point in time, Democrats are unwilling to show support for much of anything that President Trump is pushing.  That said, I am more confident that President Trump will be willing to work with Democrats and they may in turn be willing to work with him, on the right issues.

Unfortunately, the Secretary of Human Health and Services Tom Price made a career in the House of Representatives by opposing the ACA.  Now that he is the Secretary he can make regulatory changes that lessens the coverage provided by the ACA.  He can refuse to defend in it court when challenged and he can refuse to advertise re-enrollment dates and other factors that makes it harder for people to access and benefit from the Act.  Whether this will happen or not,  time will tell, but as the president and others continue to insist that the ACA will collapse, it is entirely possible that Secretary Price will help to make matters worse.

President Trump now has the opportunity to demonstrate whether or not he is the great negotiator that he claims to be.  He can choose to show real leadership and bring the parties together and do something positive for all Americans or he can show us that his “repeal and replace” sloganeering was only that — an applause line without substance.  So far his stated intention is to “move on.”

What he cannot do is claim that he no longer has any responsibility for the future of health care in the United States, which is what he tried to do last Friday.

“I think the losers are Nancy Pelosi and Chuck Schumer because now they own Obamacare. They own it – a hundred percent own it. And this is not a Republican health care. This is not anything but a Democrat health care. And they have Obamacare for a little while longer, until it ceases to exist, which it will at some point in the near future.  And just remember. This is not our bill. This is their bill.”  — President Trump on 24 March 2017

Sorry, Mr. President.  I regret to inform you that you are the president of the entire nation and that you are responsible for the well-being of all its citizens.  And oh, by the way, it was the Republicans that could not get themselves organized to pass their own bill.

Let us all work for a better deal in the future.