Congressional Republicans, who are already confronting the complex policy challenge of getting the House and Senate to agree on a plan to repeal and replace Obamacare, are learning to deal with another wildcard: the unpredictability of President Trump.
With a single tweet or interview, Trump has the ability to blow up the process. Trump, in recent comments to the Washington Post, vowed not only that his plan would provide “insurance for everybody,” but that it would cost less than Obamacare while having lower premiums and better insurance with lower deductibles.
In reality, healthcare policy is about trade-offs. Former President Barack Obama was primarily interested in expanding the number of individuals with comprehensive coverage. As a result, he signed a law that spent trillions of dollars and raised taxes to help pay for it. To ensure that those with pre-existing conditions could get covered and to limit the amount that near-retirees would pay for coverage, Obamacare forced younger Americans to purchase more comprehensive insurance than they need at skyrocketing costs, under the threat of a tax penalty.
Most Republican plans would offer lower government subsidies than Obamacare and bring down premiums by allowing insurers to offer cheaper plans with fewer mandated benefits and higher deductibles. When Trump made his statements, many in the health policy community thought that it uprooted the effort to repeal and replace Obamacare. After all, Trump’s universal coverage rhetoric sounded more like the type of single-payer system he had advocated in the past than any sort of free market solution. How could GOP policymakers possibly square the circle of universal coverage at a lower cost, without high-deductible insurance? What happens when the Congressional Budget Office inevitably finds that a less costly GOP alternative covers fewer people than Obamacare? Would Trump hold Republicans’ feet to the fire, and insist that they keep working until they come up with a plan that covers everybody?
After having witnessed this weekend’s fiasco over attendance at his inauguration, it’s become clear how the Trump White House could square the circle of differences between Republican replacement proposals and his own stated goals. Trump and his spokespeople could simply choose to lie. If White House press secretary Sean Spicer could say with a straight face that last Friday’s inauguration was the most attended ever, then why would he have any problem lying about something much more important?
That is, Republicans could pursue a replacement plan that’s along the lines of the one that Tom Price, Trump’s pick for secretary of health and human services, has proposed. When the CBO rules that it would cover fewer people than Obamacare, Trump could react by saying something along the lines of, “I see that the corrupt media is touting this dishonest report by the lying CBO. The CBO is run by the biggest liars I have ever encountered. If I had to deal with the CBO when I was in business, I wouldn’t have been able to build so many beautiful buildings. The truth is our plan covers twice as many people as Obamacare, and at half the cost. And the insurance is much, much, better. With far lower deductibles.” And perhaps subordinates with a better grasp of health policy would point out how the CBO has misjudged coverage projections in the past.
On the flip side, Trump could always pursue a plan that would be Repeal In Name Only. For instance, he could keep Obamacare’s Medicaid expansion in place, but offer some free market window dressing, as Vice President Mike Pence did when he expanded Medicaid as governor of Indiana. Or could leave Obamacare’s exchanges in place, but offer some deregulation, and more state flexibility. When conservative health policy writers such as myself point out that it’s simply Repeal in Name Only, Trump could say, “These pathetic NeverTrump people still can’t get over the fact that they were defeated badly in the election, so they’re making up lies again. I have followed through on my promise to fully repeal Obamacare, and the replacement is so much better.”
Trump has no incentive not to lie, because he lied throughout the primaries and general election, and now he’s president. Of course, just because his strategy has gotten him this far, it doesn’t mean it will work forever, especially once his policies have real world impact.
This is why I’ve argued that in the long-run, the Republicans would be much better off if they were truthful in selling their healthcare plans. Obamacare has been a political failure largely because the reality could never live up to the rhetoric Obama employed in selling it. Any lies Trump could tell about his healthcare plan will come back to haunt Republicans down the road.
