So, here we are, a little more than two months into the Trump administration. Last week’s debacle with the GOP’s efforts to “repeal and replace” the Affordable Care Act have provided valuable lessons and insights as to the strengths and weaknesses of the carnival barker in chief.
First, let’s give credit where it’s due. Trump issued an edict right out of the gate directing Congress to bring a bill to the table to fulfill one of his prime campaign promises, and in fact one of the main campaign promises that every Republican for the past seven years has run on, namely the immediate repeal and replacement of Obamacare, that evil piece of socialist legislation that dramatically reduced the nation’s uninsured rate, expanded Medicaid in those states that didn’t decline to participate, eliminated the ability of insurance companies to discriminate or refuse to provide coverage based on preexisting conditions, and put in place minimum coverage requirements for all insurance policies.
The problem was that Trump never said that the bill shouldn’t be a steaming pile of crap. For that sin of omission, what he ended up getting was – you guessed it – a steaming, runny pile of crap. Truth be told, despite the passage of seven years of promising a replacement bill, and any number of meaningless votes in the House of Representatives to repeal the ACA, the Republicans could never reach a consensus on any kind of replacement, and had no real plan to speak of. So, when it was left to Paul Ryan, the wunderkind of conservative policymaking (so we’ve been told), to cobble together a bill, what he delivered was a package which seemed to be confused as to what problems was supposed to be solving.
Whereas Trump had campaigned on the promise that everyone would be covered, with lower premiums and lower deductibles than the ACA, Ryan’s American Health Care Act (AHCA) was really just a tax cut for the rich, with lots of cuts to just about every part of the ACA which actually delivered coverage and achieved cuts in the uninsured rate. The bill gutted the ACA’s requirement that employers with over a certain number of employees provide coverage to employees; it reduced the subsidies to lower income individuals which helped them to purchase plans; it planned a phase-out of the Medicaid expansion which was an unprecedented success in delivering healthcare to the poor (except in the states where GOP governors opted out), and it eliminated the “individual mandate” which was the subject of so much right-wing hatred – but which was the only mechanism which made it feasible to require coverage of preexisting conditions. It did this by replacing it with a “penalty” for anyone who failed to maintain “continuous coverage” (more on this in a sec). But perversely, in an effort to pander to the few people who wouldn’t be harmed by all of this, it still required insurers to cover preexisting conditions. It just didn’t provide a mechanism to actually, you know, pay for that.
To anyone who even remotely understands health insurance, this thing was a disaster. Whereas Trump promised the best, the greatest, the cheapest healthcare imaginable, the Ryan plan delivered the complete opposite, and broke every promise Trump ever made on the subject during his campaign. It truly sold out those who had put him into office.
Unfortunately for the country, Trump was not a person who remotely understood health insurance. Instead, all he cared about was getting a win, and delivering on the promise to repeal and replace the ACA. The details, to him, didn’t matter. As reported in any number of media outlets, this was because he (1) had no interest in really looking into the details, which he probably didn’t understand anyway, and (2) because Mike Pence, Reince Priebus and other more traditional establishment GOP figures in his orbit convinced him it was a great plan.
So, the president went all in. He pushed for a quick up-or-down vote on the bill in the House, even after the Congressional Budget Office came up with its “scoring” on the bill, and determined that it would cause 24 million people who currently had coverage to lose it within 10 years. And, like the hastily-cobbled-together piece of shit it was, it never really had strong support even among all those Republicans who had run on the repeal-and-replace promise for seven years but still never had anything but their dicks in their hands when asked what they intended to replace Obamacare with. And statistically speaking, almost all of those lawmakers had actual dicks, by the way. Not that the GOP is a white boys’ club or anything. For moderates (most of whom are actually in the Senate) it was a non-starter, because it would force a ton of their constituents to lose coverage, either because subsidies would be going down, or because it would reverse the Medicaid expansion under which they gained coverage. For the radical right “Freedom Caucus” Tea Party miscreants, it was too generous and not nearly mean enough – but those people never wanted to “replace” the ACA with anything other than the same unregulated shit show of an insurance industry that existed before the ACA, and they’ll never actually vote for anything which offers anything in the way of subsidies or assistance to the poor. That’s just not what freedom (for insurance companies) is all about, after all.
Did that stop Trump? Nope. Being a marketer, and not much else, all he cared about was getting the win. Being able to brag that he was able to repeal and replace the ACA. “Don’t worry about the little shit” he told House Republicans. “Pass the bill.” Because he has so little intellectual curiosity or patience for the details of policy (which, incidentally, fucking matter), he never stopped to consider that that “little shit” was tremendously meaningful to real people living real lives. Most of all he wanted to be the Dealmaker in Chief. The Closer. That’s what he built his reputation on. Hell, that’s the basis of his whole public image.
It didn’t happen. Threatening incumbents with electoral losses, bullying them, and finally issuing an ultimatum and daring House Republicans to defy their vague promises didn’t make them get in line with the specifics of the AHCA. Paul Ryan getting down on his knees and begging for votes didn’t mollify the Freedom Caucus or moderate holdouts. In the end, the votes just weren’t there among the party with an overwhelming majority in the House. They had the numbers, they just didn’t have a bill that passed the smell tests for two critical factions. And they sure as hell couldn’t count on a single Democrat vote, because the AHCA was anathema to every achievement that the ACA made.
So, the dealmaker in chief couldn’t close the deal, and the bill was pulled without the humiliating defeat it would have suffered if put to an actual vote. Political capital was spent, millions of people were practically soiling their pants over the threat of losing their coverage, and Trumps approval numbers tumbled into the mid-30s, more quickly than any president in modern history.
The fact is, America and the insurance industry both dodged a bullet. The AHCA would have rapidly caused the collapse and death of the individual insurance market, and likely would have left millions without employer-provided coverage. The “continuous coverage” penalty would have been a complete failure, and starved the insurance rolls of millions of healthy young people that the industry needs to have signed up in order to cover preexisting conditions. In fact, it would have incentivized people to not buy insurance until they were older and sicker – at which point, they’d pay more for their coverage, but the insurers would still have to cover their preexisting ailments, without the benefit of all the premium dollars obtained through the young people forced to buy coverage or pay a penalty under the ACA’s individual mandate. The result would have literally destroyed the insurance industry, a completely unacceptable embarrassment for GOP politicians who have been in the pockets of that industry for God only knows how long.
So, why did it fail? Because Trump didn’t have the intellect to understand the details, didn’t have the commitment to put his nose to the grindstone to deliver a bill whose specifics didn’t completely sell out his supporters and break every promise he made to them, and because in the end, his power-play ultimatum, which might have worked against a desperate real estate seller, didn’t translate into the world of legislating. Down here, details matter, as it turns out.
The Dealmaker in Chief is a myth. It’s hype. We have a rookie in the Oval Office who is an international disgrace, who might be a decent marketer but who lacked the intelligence, patience or perseverance to go the distance and deliver on his promises, and who never understood what the bill he was pushing actually did. And this failure is bound to carry over into other agenda items as well. If Trump plans to do anything positive for this country (depending on how you define positivity), or truly deliver on his agenda, he’s going to need to do more than sign executive orders. And he appears to be completely unqualified to do what it takes. God help America.