On health care, Trump proves an un­re­li­able ally

The Washington Post Sunday - - NEWS - Dan Balz

Pres­i­dent Trump is more than his own worst en­emy. The dam­age he has in­flicted dur­ing his first five months in of­fice has un­der­mined Repub­li­can con­gres­sional lead­ers, frus­trated mem­bers of his Cab­i­net, ex­as­per­ated top ad­vis­ers and strained re­la­tions with some of the na­tion’s most im­por­tant al­lies. This week’s case study is health care.

The most sig­nif­i­cant do­mes­tic ini­tia­tive of the Trump pres­i­dency and the Repub­li­can Party is the ful­fill­ment of a prom­ise to “re­peal and re­place” the Af­ford­able Care Act. That Repub­li­cans are strug­gling to find an al­ter­na­tive to Oba­macare is plain to see. But as con­gres­sional lead­ers scratch to find the votes to pass a bill in the Se­nate, the pres­i­dent has demon­strated that he is an un­re­li­able part­ner in the bat­tle.

On Fri­day morn­ing, as Se­nate Ma­jor­ity Leader Mitch Mc­Connell (R-Ky.) was try­ing to bal­ance po­ten­tially ir­rec­on­cil­able de­mands of hard-line con­ser­va­tives and more mod­er­ate con­ser­va­tives, the pres­i­dent de­cided to of­fer his own so­lu­tion with a tweet: If the Se­nate can’t get there, why not just re­peal now and re­place some­time in the fu­ture?

Never mind that ear­lier in the year, he took the op­po­site po­si­tion. At that time, Mc­Connell and some oth­ers pre­ferred to move with an im­me­di­ate re­peal vote that in­cluded a trig­ger for im­ple­men­ta­tion some­time in the fu­ture, giv­ing elected of­fi­cials the abil­ity to say they kept a prom­ise and enough time to try to find a re­place­ment. But the pres­i­dent over­rode that idea, de­mand­ing that re­place­ment had to ac­com­pany re­peal.

Now, at the worst pos­si­ble mo­ment, Trump seemed to have shifted again, leav­ing Se­nate law­mak­ers frus­trated and baf­fled.

The idea of go­ing to re­peal now, re­place later was not orig­i­nally the pres­i­dent’s. His tweet came min­utes af­ter Sen. Ben Sasse (R-Neb.) made a sim­i­lar state­ment on “Fox and Friends.” Sen. Rand Paul (R-Ky.), a hold­out, has been say­ing the same thing.

The pres­i­dent ap­pears to have no com­mit­ment to an ex­plicit strat­egy for get­ting a health-care bill to his desk, only a de­sire for vic­tory and lim­ited pa­tience for the leg­isla­tive process. He also has no fixed views on the sub­stance of health-care re­form, hav­ing made con­tra­dic­tory state­ments about the topic through­out his cam­paign and since.

He has said he wants a health­care sys­tem with heart, one in which ev­ery­one is cov­ered. But he em­braces leg­is­la­tion that would leave 22 mil­lion to 23 mil­lion ad­di­tional Amer­i­cans with­out cov­er­age by 2026, ac­cord­ing to the Con­gres­sional Bud­get Of­fice. When the House passed its health-care bill in May, he show­ered it and GOP lead­ers with praise. Later he called the mea­sure “mean.” He cam­paigned against cuts in en­ti­tle­ments — Medi­care, So­cial Se­cu­rity and Med­i­caid. The con­gres­sional leg­is­la­tion would re­vamp Med­i­caid, sig­nif­i­cantly slow­ing the growth in spend­ing.

Pres­i­den­tial lead­er­ship on th­ese big do­mes­tic ini­tia­tives gen­er­ally re­quires a com­bi­na­tion of two things. The pres­i­dent is ex­pected to act as the lead­ing sales­per­son, mak­ing the public case while leg­is­la­tors make the sausage. Be­hind the scenes, a pres­i­dent works to bring along the last wa­ver­ing law­mak­ers, call­ing, ca­jol­ing and ap­ply­ing the pres­sure. Some­times it doesn’t work, but those re­spon­si­bil­i­ties are part of the job de­scrip­tion of the pres­i­dency.

For­mer pres­i­dent Barack Obama spent months pub­licly ad­vo­cat­ing in fa­vor of the Af­ford­able Care Act and the value of ex­panded cov­er­age and try­ing to slow the growth of med­i­cal in­fla­tion. De­spite his lim­ited en­thu­si­asm for in­ter­act­ing with Congress, he also spent hours in pri­vate con­ver­sa­tions with leg­is­la­tors, in­clud­ing some Repub­li­cans. He never won GOP sup­port, nor was his mea­sure pub­licly pop­u­lar while he was in of­fice, but not for lack of ef­fort.

Through the first five months of his pres­i­dency, Trump has yet to de­liver a sin­gle com­pre­hen­sive speech on the topic or sub­jected him­self to ex­ten­sive ques­tion­ing from re­porters that would give him a fo­rum to make his case. Nor is there ev­i­dence that the pres­i­dent has proven ef­fec­tive with many in­di­vid­ual law­mak­ers.

Trump’s busi­ness record sug­gests he is an en­thu­si­as­tic sales­man. But the kind of hy­per­bole that some­times goes with real es­tate deals doesn’t work so well in gov­ern­ment. Mak­ing the public case and per­suad­ing re­luc­tant law­mak­ers re­quires a fa­mil­iar­ity with the sub­ject mat­ter that he has yet to demon­strate. What is the af­fir­ma­tive case he makes for the re­place­ment now un­der con­sid­er­a­tion?

Trump’s most-re­peated ar­gu­ment is that Oba­macare is im­plod­ing. It is cor­rect that there are prob­lems of cov­er­age in some places, as re­ports of in­sur­ers pulling out of some mar­kets at­test, and that pre­mi­ums have risen. Repub­li­cans blame it on the flaws of Oba­macare; Democrats say the uncer­tainty cre­ated by the on­go­ing de­bate makes in­sur­ers un­will­ing to place risky bets on the prof­itabil­ity of of­fer­ing cov­er­age.

The Con­gres­sional Bud­get Of­fice anal­y­sis of the Se­nate bill re­leased last week of­fered a por­trait of the cur­rent sys­tem that is less apoc­a­lyp­tic than the pres­i­dent’s rhetoric. The CBO re­port stated that, in part be­cause of the in­di­vid­ual man­date un­der Oba­macare, the de­mand for in­sur­ance will con­tinue to be strong enough “for the mar­ket to be sta­ble in most ar­eas.”

CBO said the Se­nate bill as it stood at the be­gin­ning of last week also would re­sult in gen­er­ally sta­ble in­di­vid­ual mar­ket­places. The re­port cau­tioned, how­ever, that be­cause of unan­swered ques­tions sur­round­ing the new law, there could be some dis­rup­tions in those mar­kets in the short term. But the CBO said that mar­kets would gen­er­ally be sta­ble un­til 2020, in part be­cause the gov­ern­ment would keep pay­ing sub­si­dies that help lower-in­come cus­tomers in ACA health plans af­ford out-of-pocket ex­penses.

Even af­ter that, in­di­vid­ual in­sur­ance mar­kets in most of the coun­try would be sta­ble, the CBO said, al­though it noted that un­der ei­ther Oba­macare or the Se­nate’s plans, some ru­ral ar­eas could run into trou­ble. Un­der the Se­nate bill, the anal­y­sis said: “The re­duc­tions in sub­si­dies would lead fewer peo­ple to de­cide to pur­chase in­sur­ance — and mar­kets with few pur­chasers are less prof­itable for in­sur­ers.”

The health-care dis­cus­sions should be a top pri­or­ity for the pres­i­dent, given Mc­Connell’s de­sire to get to a vote as quickly as pos­si­ble af­ter the Fourth of July re­cess. Pas­sage of a re­place­ment for the Af­ford­able Care Act would make it pos­si­ble for Congress to move on to tax re­form, which the pres­i­dent cares a lot about, and other parts of his and the GOP’s agenda.

Yet as Se­nate Repub­li­cans were in com­plex dis­cus­sions to re­solve their dif­fer­ences, the pres­i­dent cre­ated an­other need­less dis­trac­tion with his crude and sex­ist at­tack tweet Thurs­day aimed at MSNBC’s Mika Brzezin­ski. That tweet was not the first time Trump has den­i­grated women. Once again, it put Repub­li­cans in the awk­ward and em­bar­rass­ing po­si­tion of try­ing to turn their heads with­out truly walk­ing away from the pres­i­dent.

The at­tack on Brzezin­ski and Joe Scar­bor­ough, co-hosts of the “Morn­ing Joe” show, is part of an on­go­ing war with main­stream me­dia that the White House is now wag­ing on a near-daily ba­sis. That con­flict cheers the pres­i­dent’s base and helps keep those loy­al­ists close to him de­spite his other dif­fi­cul­ties.

Con­gres­sional Repub­li­cans may ab­hor what the pres­i­dent said with his tweet at­tack on Brzezin­ski, but they are not ready to risk true con­fronta­tion with Trump and there­fore his core sup­port­ers, whose en­thu­si­asm they will need in the midterm elec­tions.

The pres­i­dent’s sug­ges­tion to re­peal now and re­place later begs the larger ques­tion for Repub­li­cans. GOP law­mak­ers have spent years cam­paign­ing against Oba­macare, and over the past months, in both houses of Congress, hours and hours of gran­u­lar dis­cus­sions have been held.

The prob­lem is not one of need­ing more time to come up with a per­fect so­lu­tion. It is the ques­tion of whether Repub­li­cans are pre­pared to stand be­hind their crit­i­cisms of Oba­macare and the po­lit­i­cal con­se­quences that could come with sig­nif­i­cantly re­vis­ing it.

Repub­li­can elected of­fi­cials have cam­paigned as the party of smaller gov­ern­ment, lower taxes and less fed­eral spend­ing. The re­sult of that ap­pears to be a health-care bill that would knock mil­lions and mil­lions off the cov­er­age rolls, in­clud­ing many lower-in­come Amer­i­cans now on Med­i­caid. To date, the out­lines of that so­lu­tion have found lit­tle sup­port from the public.

Mc­Connell will plunge ahead with a re­peal-and-re­place ef­fort, de­spite the pres­i­dent’s in­ter­jec­tion. Repub­li­cans now have a choice. Ei­ther they sup­port that kind of pack­age or they don’t. They can’t look to the pres­i­dent on this: He has pro­vided lim­ited help and lit­tle po­lit­i­cal cover. If any­thing, he’s made their task even more dif­fi­cult as the past week showed.

JABIN BOTSFORD/THE WASH­ING­TON POST

Pres­i­dent Trump at­tends an Oval Of­fice meet­ing Fri­day in the White House. The pres­i­dent has piv­oted sev­eral times on Repub­li­cans’ health-care leg­is­la­tion as the party strug­gles to build con­sen­sus.

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