When even the most committed Republicans came around to support Donald Trump in 2016, they made a kind of bet. It wouldn’t matter much that Trump had no apparent fealty to conservative ideology or that he was a complete ignoramus about policy because he’d be leaving all that boring stuff to them. The Republican Congress would pass its agenda, he’d sign whatever they put in front of him, and they’d all live happily ever after.
But now it’s not looking so simple. In fact, Trump just dealt a huge blow to their top priority: repealing the Affordable Care Act. Accomplishing repeal without causing the GOP a political calamity is an extremely delicate enterprise, and the last thing they want is to have him popping off at the mouth and promising things they can’t deliver. Which is what he just did, as The Washington Post reported Sunday:
“President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of ‘insurance for everybody,’ while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid . . .
“Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — ‘lower numbers, much lower deductibles’ — he said he is ready to unveil it alongside [House Speaker Paul] Ryan and Senate Majority Leader Mitch McConnell. . . .
“Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.
“‘We’re going to have insurance for everybody,’ Trump said. ‘There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.’ People covered under the law ‘can expect to have great health care. It will be in a much-simplified form. Much less expensive and much better.’ . . .
“‘It’s not going to be their plan,’ he said of people covered under the current law. ‘It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people ...’ ”
We should begin with the assumption that nothing Trump says can be taken at face value; the “plan” that he claims is being devised could be no more real than the secret plan to defeat the Islamic State he used to claim that he had formulated.
But that’s not the point. What matters is this: Donald Trump just emphatically promised universal health coverage. That’s an absolutely gigantic promise, and it’s one that Republicans have no intention of keeping.
But now they’re stuck with it. Democrats will be saying, “President Trump promised that everyone would be covered!” every day for as long as this debate goes on. Every time a congressional Republican is interviewed on this topic, they’ll be asked, “President Trump said that everyone would be covered. Does your plan do that?,” and they’ll have to bob and weave as they try to avoid admitting the truth.
That’s because the Republican plan, in whatever final form it takes, will absolutely, positively not cover everyone. Universal coverage isn’t even one of their goals. Republicans believe it’s much more important to get government as far away from health care as possible. In place of the ACA’s expansion of Medicaid and subsidies for the purchase of insurance that have extended coverage to 20 million more people than used to have it, they’ll be offering some tax credits and health savings accounts, which would be very good for the healthy and wealthy, but not so great for other people.
They call this “universal access,” which is meant to sound like “universal coverage” but is actually nothing of the sort. The truth is that there are really only two ways you can achieve universal coverage: by having the government cover everyone in some form of single-payer, or with a set of extremely coercive mandates to carry coverage, much more coercive than the ones in the ACA. Republicans would rather pluck out their own eyes than agree to either one of those. So the trick is to make the public think they won’t take away coverage from tens of millions of people while doing just that.
That requires some rhetorical subtlety, something Trump is just not capable of. Here’s more evidence: Trump’s insistence that the Republican plan will give people “much lower deductibles” is absolutely false. In fact, every extant Republican plan promotes higher deductibles as a way of forcing people to become aggressive health-care shoppers because they have “skin in the game” and, thereby, through the magic of the market, driving down costs.
If Trump understood the political and policy challenges Republicans face, he’d know that high deductibles are supposed to be complained about and wielded as evidence that the ACA is a failure, but you’re not supposed to actually promise that any Republican plan will lower them. You want people to assume that, of course, but you don’t want to promise it directly, because then you might be held accountable for that promise.
But Trump says whatever comes into his head, and whatever seems like it might be popular. People hate out-of-pocket costs, so he promises low deductibles. People don’t like the idea of tens of millions losing their coverage, so he promises that everyone will be covered.
And now, congressional Republicans are going to have to answer for breaking a promise they didn’t even make. At a moment when opposition to the repeal of the ACA is gathering strength, this was the last thing they needed.
Paul Waldman is a senior writer at The American Prospect.