Since President’s Trump’s election, worried centrists and progressives have entertained the hope that the populists in the president’s circle, though scary in their own ways, will nevertheless restrain the more traditional Republicans in the White House. Maybe chief strategist Stephen K. Bannon will convince Trump to invest in infrastructure and defend the social safety net, even as Vice President Pence and chief of staff Reince Priebus discourage the president from embracing the alt-right.
This rosy scenario is not playing out, as an email zooming out of House Speaker Paul Ryan’s (R-Wis.) office Tuesday night showed: “There we go,” Ryan spokeswoman AshLee Strong wrote even as her boss was still watching Trump finish delivering his first address to a joint session of Congress. “Tonight was a big night for Republicans’ efforts to repeal and replace Obamacare.” Soon after, Ryan himself called Trump’s speech “a home run.” Why? “Congress and the White House are united in our promise to repeal Obamacare and replace it with a patient-centered system. Tonight, we made progress on that pledge as President Trump demonstrated that he and the House are coalescing around a replacement plan.”
Specifically, Trump embraced the broad principles for replacing the Affordable Care Act that Ryan and other mainstream Republicans have advocated for years: providing tax credits to help people buy insurance, super-charging health savings accounts, eliminating insurance coverage requirements and adding “flexibility” to — a euphemism for “cutting” — Medicaid.
Since Obamacare passed, various GOP plans based on these principles have been floated, and they have reliably raised concerns among experts that they would fail to cover nearly as many people as the ACA does, and that those who manage to afford insurance would have much flimsier plans. One major reason: Along with requiring that insurers cover primary care and a variety of “essential” treatments, Obamacare ties the amount of premium assistance people get to their incomes — yet Republicans would abolish this feature, which currently ensures that affordability is at the center of the government’s health-care subsidy system for the individual insurance market. Under the major GOP replacement plans, wealthier people would get more benefits, and needier people would almost certainly get fewer.
Leading into Trump’s speech, conservative House Republicans had revolted against this policy design — perversely, because they deemed it too generous, not too paltry. The president, meanwhile, seemed adrift on Obamacare replacement. “Nobody knew that health care could be so complicated,” he said Monday, amid reports that he was waffling between Ryan’s design and more moderate proposals from people such as Ohio Gov. John Kasich (R).
But Trump embraced the Ryan repeal-and-replace template Tuesday night, before the largest television audience he is likely to have all year. Notch a victory for traditional Republicans, and a blow to those who hoped — against hope, really — that the White House’s ideological factions would check each other’s excesses.