A day after the surprise announcement, in the form of a Monday court filing, that the Justice Department would not defend any part of the Affordable Care Act in court, President Trump tweeted: “The Republican Party will become ‘The Party of Healthcare!’ ”
In part, this was just the usual bluster from a president more focused on political branding than policy detail. But it was also part of a line of thinking on Trump’s part, going back decades, in which he insists that there’s some great, affordable, easy-to-implement, politically popular health-care plan waiting in the wings, if only a sufficiently bold leader — him — will step up and make it happen.
Trump’s plan isn’t a plan at all. It’s a political fantasy that doesn’t acknowledge the hard choices that are an inevitable part of any health-care system. And that refusal will likely put Trump and the GOP into a political and policy bind.
Discussing health care in his 2000 book, “The America We Deserve,” Trump wrote: “I’m a conservative on most issues but a liberal on this one.” It was “unacceptable” that so many Americans were uninsured, he said. “Working out detailed plans will take time. But the goal should be clear: Our people are our greatest asset. We must take care of our own. We must have universal healthcare,” Trump wrote. He proposed basing a system on federal employee benefits, but provided hardly any specifics.
On the campaign trail, Trump made similarly broad promises: “I am going to take care of everybody,” he told “60 Minutes” in 2015. “I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.” When asked how, he added, “The government’s going to pay for it. But we’re going to save so much money on the other side.” He praised foreign single-payer systems while promising to replace Obamacare with a system based on private plans. What sort of system would that be? “Something terrific,” he told CNN in July 2015.
In the Fox News GOP primary debate in August 2015, he said, “As far as single payer, it works in Canada. It works incredibly well in Scotland.” In the United States, “It could have worked in a different age.” He went on to say: “What I’d like to see is a private system without the artificial lines around every state” but didn’t elaborate on how that would work. And his answer didn’t reflect that Obamacare has an unused provision allowing “compacts” between states that would allow insurers to sell coverage across state lines.
More than two years into the Trump presidency, Obamacare remains on the books, and there is no replacement. Although Republicans shuffled through replacement plans during the failed 2017 repeal effort, and the administration has made a number of tweaks to the law, Trump himself has never put forth a comprehensive proposal of his own.
Of course, no one thinks of the president as a policy wonk. He thinks in slogans and boasts, not the careful weighing and prioritizing that even the most basic health policy plans require. But even if he were somewhat better-versed in the details, the health-care plan he seems to want — a plan that covers everybody, saves money and is built around choice and competition — doesn’t exist.
A full-fledged single-payer system favored by Sen. Bernie Sanders (I-Vt.) would be highly disruptive, increase federal spending by trillions and force every American into a government-run health plan. According to estimates from both the Urban Institute and the Mercatus Center, the Sanders plan would add about $32 trillion to the federal tab over a decade. Further, that plan, potentially, would end the private health insurance market as we know it in just four years.
In the United States, a system based on private plans sold through heavily regulated marketplaces would look a lot like Obamacare, which the Trump administration is trying to overturn in court. Simply eliminating the Affordable Care Act without any replacement would return the country to the pre-Obamacare status quo, which Trump himself found unacceptable. Yes, there are foreign systems that cover most everyone through private plans, but neither Democrats nor Republicans are proposing that we adopt them, in part because they would require upending popular public payers such as Medicare — which Trump himself has sworn he won’t cut.
The “terrific” plan of Trump’s imagination simply doesn’t exist. Instead, there are unavoidable choices and trade-offs, a difficult balancing of cost, coverage and political feasibility. And Trump and his fellow Republicans have, with a few exceptions, refused to make or even acknowledge those trade-offs.
One of the most revealing aspects of the GOP’s 2017 repeal-and-replace effort was the lack of public salesmanship, from both Trump and Republican leadership. In 2009, as the Affordable Care Act was making its way through Congress, President Barack Obama toured the country making the case for the law, and gave a lengthy address to Congress devoted to explaining how it would work and why he believed it would represent an improvement over the status quo. Trump, despite his penchant for salesmanship, made no similar effort, and provided little indication that he understood how various Republican plans worked. Congressional Republicans frequently came across as similarly confused about their proposals.
It’s not just that they didn’t understand the particulars; they didn’t have the big picture, either. There was no vision, no broadly shared goal. Republicans didn’t just lack a plan — they lacked an underlying idea.
Which doesn’t mean Republicans have never had any ideas. It’s just that they all fall short of what Trump says he supports: Block granting Obamacare to the states, like Sens. Lindsey O. Graham (R-S.C.) and Bill Cassidy (R-La.) have proposed, wouldn’t result in universal coverage. Other conservative plans would alter Obamacare’s rules governing preexisting conditions, requiring insurers to cover people only if they maintain continuous coverage. And even if the president decided to buck his party, the single-payer plans Trump has flirted with would leave little room for private competition. Any choice leaves something wanting, which is probably why Trump has opted not to make a choice.
Democrats have successfully used the GOP’s lack of vision against them. Exit polls indicate that Obamacare’s preexisting conditions rules were the single biggest issue for midterm voters. In a meeting last month, House Minority Leader Kevin McCarthy (R-Calif.) accepted this explanation for the GOP’s midterm fate. And Democrats have already signaled that they’ll emphasize health care in the 2020 election, including the administration’s refusal to defend the law in court.
The legal arguments in the administration’s case are weak, so there’s a good chance it will fail on appeal, and Trump appears to have no fallback plan if it succeeds. After Senate Republicans lunched with Trump this week, Sen. Marco Rubio (R-Fla.) said Trump “didn’t offer a plan.” How could he? There isn’t one to offer.
Republicans won’t be “The Party of Healthcare” unless they begin to acknowledge the trade-offs involved and work to articulate their own vision of what health policy is for. Until then, all they’ll have to offer is something vague and terrific — which is to say, something that doesn’t exist.