President-elect Donald Trump gave his first extended comments on Obamacare Friday, suggesting he may be rethinking the wisdom of taking a sledgehammer to the law, as he has promised to do. But it’s not clear whether Trump meant to signal a shift in his position, or whether he was simply speaking off the cuff.
In his first interview since winning the presidential election, Trump told The Wall Street Journal he was still committed to moving quickly to deal with the Affordable Care Act a program, he said, that is offering coverage so expensive that “you can’t use it.”
But Trump also mentioned that he would look at parts of the law that seemed to be worthwhile, including protections for people with pre-existing conditions who previously had no access to insurance. One reason, he said, was that President Barack Obama urged Trump to think about those provisions when the two met on Thursday. “I told him I will look at his suggestions, and out of respect, I will do that,” Trump said.
By itself, that pledge doesn’t signify much. Repeal advocates always talk about keeping provisions like the pre-existing condition guarantee which is highly popular, although difficult to make work without some other elements of the law in place.
In addition, Trump’s specific commitments on health care policy, like his commitments on all policies, have been inconsistent and sometimes contradictory. They are difficult to take seriously.
But Trump said one other intriguing thing about the law. He vowed that “either Obamacare will be amended, or repealed and replaced.”
Note the key word: “amended.” That could have a little more significance.
Republicans have been trying to repeal Obamacare ever since it became law in 2010. And with Trump about to become president, they can finally do it. But promising to repeal the law is one thing, and following through on that promise is quite another.
Whatever its pluses and minuses, the health care law is now firmly entrenched in the American health care system. It has brought the number of uninsured Americans to a record low, and now directly provides insurance to more than 20 million people some through an expanded Medicaid program, and others through “exchanges” that make regulated, subsidized insurance available to people who don’t have access to employer coverage.
Partly for these reasons, Republicans and their allies have always vowed to “replace” Obamacare with an alternative that, as Trump liked to say, would provide “great” health care at lower costs. But actually devising such a system will be difficult.
Pretty much any realistic alternative to Obamacare would entail its own set of unpleasant tradeoffs delivering cheaper coverage for young and healthy people, perhaps, but only by making coverage less comprehensive or less available for older and sicker Americans.
Similarly, many conservative schemes would reduce government spending and lower taxes on the wealthy but only by taking away the financial assistance that has enabled so many millions to get coverage they could never get before.
Earlier this year, Republicans passed a proposal that would have preserved the pre-existing condition requirement while ripping out the law’s funding. The result, according to the Congressional Budget Office, would have been 22 million people losing health insurance.
That was largely a consequence-free vote, since Republicans knew Obama would veto it. Crafting a proposal that could actually become law is bound to be politically difficult. Republicans will have to go through the same exercise Democrats did in 2009 and 2010 attempting to please constituencies in and out of Washington, and finding some way to broker compromises among different factions within their own congressional caucuses.
And any changes are bound to create painful disruptions the kind that greeted Democrats when the law took effect in 2014, fueling a political backlash that likely played at least some small role in Hillary Clinton’s defeat and Trump’s victory on Tuesday.
For that reason, it’s conceivable Republicans could decide to pass a law that they can label as “repeal and replace” but that mostly modifies the existing system say, by loosening the regulations on insurance companies and reducing taxes that finance the program. Doing so would allow them to avoid the hugely painful disruptions that total repeal would entail.
A report from health care journalist Caitlin Owens, posted Thursday on LinkedIn, said that on Capitol Hill, aides were just coming to grips with the fact that repeal could be difficult and that, as a result, Republicans might decide to leave significant parts of the law in place.
“We’re in rapid detox of holy crap,” one aide told Owens. “We have to actually do this.”
Stopping short of full repeal would involve its own political peril, of course. Right-wing groups eager to rip out Obamacare, root-and-branch, would be furious. And, to be clear, it’s entirely possible Trump’s statement was just poor phrasing and that aides will quickly clarify his remarks to make clear he remains committed to full repeal.
But chances are good that Trump has never spent much time thinking about how the health care law actually works, let alone how to replace it. After finally confronting the real effects of repeal, he might not want to be the president whose term begins by yanking insurance from millions of people many of whom, assuredly, count themselves among his supporters.
Elections have consequences, yes. But governing does too.
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