Today President Trump, House Speaker Paul D. Ryan (R-Wis.), moderate House Republicans and Freedom Caucus Republicans risk their jobs, their credibility and their agenda. How could this have gone differently, without the potential for political self-immolation? Consider some alternative scenarios.
In the first, Trump could have stuck to his campaign populist themes. Rather than defer to Ryan and to Health and Human Service Secretary Tom Price (whose plan was essentially what Ryan had in mind all along), he could have put forth a populist-styled plan: Keep the taxes on the rich, put additional money into funding state-based reinsurance plans for high-risk individuals, encourage insurers to reenter the exchanges either by reopening the risk corridors or by altering the 80-20 rule and look to GOP governors for a Medicaid reform plan that allows expanded coverage in exchange for state flexibility in program design. Trump could also have followed through on his promise to allow the federal government to negotiate directly with drug companies.
Republican hard-liners would have hated nearly all of that — as they do the current bill — but the president could have put his weight behind it, lured in Democratic support and come out with something that passed the straight-face test. The Senate would work its will, with Majority Leader Mitch McConnell (R-Ky.) there to construct a bipartisan coalition. That scenario would have left the Freedom Caucus out in the cold — or out of business — but set the tone for a bipartisan, populist agenda.
Another scenario would have recognized that health care is, in fact, “complicated.” The White House has begun not so quietly expressing buyer’s remorse about starting the agenda with health care. Had the administration started with an infrastructure bill or a tax bill (including corporate tax reform and middle-class tax cuts), Trump might have gained momentum. There likely would have been some bipartisan agreement on those issues so long as the GOP resisted the urge to deliver big tax cuts for the rich.
Neither of these approaches would have guaranteed a “win” — which is all Trump really cares about. However, the chances for success might have been greater. Moreover, Republicans would not have handed Democrats a club with which to pound GOP members. The current health-care bill perfectly encapsulates the stereotype of the heartless, pro-rich (tax cuts for the richest), anti-poor (cuts in Medicaid), anti-woman (temporarily eliminate Planned Parenthood funding, remove essential coverage element, including pregnancy, maternity and newborn care) Republican. And increasing costs for older, rural voters delivers a cruel blow to Trump’s base.
This is precisely what Stephen K. Bannon is now complaining about, as Gabriel Sherman reports:
Publicly, Bannon has been working to help the bill pass. But privately he’s talked it down in recent days. According to a source close to the White House, Bannon said that he’s unhappy with the Ryan bill because it “doesn’t drive down costs” and was “written by the insurance industry.” While the bill strips away many of Obamacare’s provisions, it does not go as far as Bannon would wish to “deconstruct the administrative state” in the realm of health care. Furthermore, Bannon has been distancing himself from the bill to insulate himself from political fallout of it failing. He’s told people that Trump economic adviser Gary Cohn — a West Wing rival — has run point on it. (Bannon did not respond to a request for comment.)
Trump and Ryan may pull out a win after all. The vote as of this moment is too close to call. Heritage Action remains opposed, however. Numerous moderate representatives have repudiated it. Polling shows that the public intensely dislikes the bill. In other words, this is a lose-lose proposition for Republicans. The Senate almost certainly will reject the current House bill, leaving the GOP and the administration mired in the health-care battle for some weeks or months. Keep in mind as this plays out that none of this was inevitable.