Trump’s Obamacare Debacle: Vanquished by a Ghost!

Trump’s Obamacare Debacle: Vanquished by a Ghost!

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Judging by the dazed expression on President Trump’s face at his Friday afternoon press conference, it is clear that he never saw his first major political defeat coming. It was as if he had stepped off the curb looking the other direction into the path of an uncoming bus.

The key to any political victory is situational awareness- clarity about your goals and mastery of the details. There were warning signs of a potentially fatal disengagement, for example, in Trump’s periodic references to “the healthcare” when discussing the issue.

It doesn’t make Trump’s political pain any more bearable to know that he was mugged by a ghost, by a potent political symbol nourished by the Obama administration. The stunningly rapid political failure of the American Health Care Act more resembled a botched exorcism than a serious exercise in health policy.

From his successful campaign, Trump knew that repealing and replacing ObamaCare was the most reliable thunderous applause line in his stump speech. This visceral connection moved the issue to the top of his political agenda. To Trump’s political base, repealing ObamaCare was striking a blow against a paternalistic all-knowing federal government, against interference in citizens’ private lives, against confiscation and redistribution of peoples’ wealth, to a new “entitlement” program, but most of all, against a President they reviled.

What his base really wanted to do was banish the Obama legacy symbolized by this legislation. Abolishing the reality of Obamacare, which needed to be addressed by detailed legislation, was very different, messier and more complex than erasing the symbol. The real Obamacare was a bewilderingly complex and sprawling mish mash of liberal good works intended principally to reduce the number of the nation’s uninsured.

Unraveling Obamacare the Law without leaving a politically damaging, gaping hole in the healthcare system was a daunting and complex technical challenge which easily evaded an inexperienced new Republican majority in Congress. The political challenge was made even more complex by Trump’s running far to the left of his Congressional base in wanting to preserve coverage gains for the formerly uninsured.

The core of Obamacare was a partial federalization of one of the twin pillars of the Great Society, the Medicaid program (scaled back by the Supreme Court in 2012), as well as a partial federalization of the nation’s private health insurance market. But that was only 10% of the 900 plus page law. There was also the removal of the hated “doughnut” hole in the 2003 Medicare drug benefit, a charter for experiments with new Medicare provider payment models, new health manpower provisions, a reform of the US Indian Health Service, public health funding enhancements, a new federal agency to evaluate the effectiveness of medical technology, a raft of new taxes to fund its provisions and literally dozens of other things, all enswathed in gigantic heaps of almost unreadable legislative prose.

The circle of people substantively aware of ACA’s actual scope and complexity included at most a couple thousand Democratic health policy wonks, legislators and their staffs, and reporters- none of whom were at Trump’s side when he began his doomed crusade. Some members of Trump’s majority, notably Senator Lamar Alexander, could be heard at the late January Republican retreat pleading with his colleagues to narrow their focus to the troubled health insurance reforms in ACA and not attempt “full repeal”. These voices of reason were brushed aside in a bloody rush to uproot as much of the law as humanly possible in a short period of time.

The origins of Trump’s political embarrassment are buried not only in his White House’s lack of substantive knowledge of the law, but also deep public ignorance of what ACA actually did. By the summer of 2009, anger at the Obama Administration’s perceived failure to address the nation’s economic crisis (despite a stimulus bill and auto industry bail-outs), was boiling over in angry town hall meetings and the rise of the Tea Party.

Concerned about rapidly deteriorating political polls, Obama’s political advisors urged him to change the conversation after signing the ACA on March 23, 2010. The President’s political advisors viewed health reform as a quixotic “legacy” Democratic political project and had misgivings about leading with it in the first place. Given the dire economic circumstances, further focus on the ACA was digging a deepening political hole deeper.

So the administration basically walked away from ACA, and invested virtually no energy or resources in explaining to people how the law actually benefited them. Obama’s advisors were right about the rising anger part. Less than eight months later, in the 2010 mid term elections, voters stripped Democrats of control over the House of Representatives in the most stinging electoral repudiation of any political party in 72 years!

But by moving on, and failing to educate the public of ACA’s benefits, the President left the law’s growing rank of opponents free to define what it was. Because the ACA was intimidatingly opaque, even to experienced policy analysts, it was far from obvious what it did or whether it was going to work.

Failing to explain in plain English how the law benefited Americans was a fundamental political failure. The law became, by default, a gigantic Rorschach blot onto which the public could project their emotions about government. For progressives, ACA was an extension of the New Deal and Great Society, a merciful government keeping its promise to provide security to Americans. For the Tea Party, and the emerging alt-right movement, the ACA was an assault on liberty, an onrushing phalanx of black helicopters, a government take over of the health system, etc. But most important, for the right, “ObamaCare”, as its enemies called it, was about Obama, and his vision of the country.

By failing to explain to people what was done in their name, Obama effectively orphaned the law. And the result: ACA achieved 50% approval ratings in Kaiser Family Foundation’s tracking poll for exactly one month in the ensuing seven years. http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-future-directions-for-the-aca-and-medicaid/ Even as Congress debated killing it, it only reached 48% approval in February, 2017. The Kaiser poll also repeatedly confirmed vast ignorance of the law’s contents (e.g. the presence of “death panels”, covering “illegal aliens”, who was actually eligible for coverage, and the like). The law’s opponents largely succeeded, by default, in the battle to define ACA politically.

Obama added color (bright red!) to the law’s image by embracing the label “Obamacare”, co-opting the Republican slur on the ACA. The logic was, “Well, since it is really going to help people, why not put our name on it?” In retrospect, embracing the radioactive partisan label Obamacare was the equivalent of a tacky end zone celebration, a form of political taunting. This made the law more vulnerable, because it closely tied the ACA to a particular person.

Social Security was a political lift for the New Deal, a lift that would have been much heavier had it been labeled “RooseveltCare”. Was it merciful political restraint or mere prudence that prevented Lyndon Johnson’s White House from rebranding Medicare and Medicaid as “JohnsonCare”? These measures were controversial in their day, but evolved over decades into part of our social infrastructure.

Embracing the “Obamacare” label for the Affordable Care Act made it all the more tempting a political target, and by the sheer rage it evoked on the alt-right, might actually have helped intensify the political energy behind “repeal and replace”. What overwhelmed the Republican Party last week was almost like the political equivalent of an auto-immune reaction to a bee sting.

The law’s image was also damaged by the catastrophic roll out of Healthcare.gov in October, 2014, the “if you like your health plan, you can keep your health plan” fiasco when ACA’s grandfathering provisions went into effect and the surge of individual and small group insurance rates as the Exchanges opened for business. This infuriated many innocent bystanders (including this author’s wife, who received a 62% renewal quote for the small group insurance for her florist business in the fall of 2014).

That these problems could have overshadowed the ACA’s headline success story- covering over 20 million formerly uninsured people and doing so without igniting a new round of health cost inflation- should tell you something about our present political moment.

In retrospect, things could have gone worse on the Trump Administration’s maiden voyage into health policy. They could have failed slowly, and dragged the divisive debate over the future of ACA into next year’s off year election cycle. OR they could actually have passed the American Health Care Act and been swamped by the damage done to their base of working class voters, millions of whom would have found themselves without health coverage http://thehealthcareblog.com/blog/2017/03/08/the-rust-belt-is-burning-republicans-lay-waste-to-their-base-on-health-reform/ “Failing fast” may actually have been the least worst political outcome for a Trump Administration. By failing to understand the complexities of the actual law, and being seduced by the taunting symbol of the previous administration, the Trump Administration fell into a political trap.

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30 Comments on "Trump’s Obamacare Debacle: Vanquished by a Ghost!"


Member
Steve2
Apr 1, 2017

Trump still doesn’t know much, or care, about health care policy, but he does hate to lose. I would expect that another bill will pass fairly soon. There won’t be much change in policy, but it will pass as a result of political pressure (threats or carrots) on the holdouts. That will get it through the House. I am less certain of the Senate. They may be less likely to take one for the team.

Steve

Member
Allan
Apr 1, 2017

(Trump)” he does hate to lose. ” We should all vote for generals that like to lose? That doesn’t make a lot of sense.

Member
Allan
Mar 30, 2017

“Failing to explain in plain English how the law benefited Americans was a fundamental political failure. ”

Can’t say this post was very revealing of anything or merits more than a sigh. The author doesn’t like Trump. The author doesn’t recognize his personal lack of fondness and opinions don’t matter one iota to Trump. Trump will keep plugging away despite the authors disdain and the disdain of the Democrats and a good number of Republicans. All of them wish to forget the American people voted Trump President. Hillary with all her lies and self serving dealings including involvement of the sale of uranium to the Russians is still the pristine candidate of the left. Bernie Sanders may have won if the Democratic leadership wasn’t so dishonest to those of their party. It appears the Democratic mind of today has absolutely no memory of things that should never have been done by one of their own.

Then I have to add the quote at the beginning of my response. More material to sigh over. Yes, there were some benefits to the ACA and some ideas that were actually conservative ideas, but the ACA was a total failure and though one could point out some benefits the failures were so great that one can only label the bill a total failure. I had to stop there because I was falling asleep listening to the constant bashing that had little to no content.

Member
Jeff Goldsmith
Apr 1, 2017

Wasn’t a question of my feelings for Trump. Whatever my sentiments, he is our President for four years, and what he promised to do- revitalizing our economy in particular- is vitally important. All Presidents make mistakes at the beginning of their terms. Johnson escalated the Vietnam War. Kennedy invaded Cuba, a mistake the Obamacare debacle resembles in more than a few ways.

Trump would not have been elected in the first place if he had campaigned on the AHCA.
As I said, he ran way to the left of his Congressional base. He promised not to cut Social Security and Medicare, important issues to his voting base, which was a median 57 yrs old and most of whom will have nowhere else to turn in their so-called “golden years”.
He also promised not to strand the 20 million people who were newly covered under ACA and give them better coverage. Was that just campaign rhetoric?

What he failed to grasp was that the core goal of his Congressional base was to cancel the trillion dollar tax increase that funded ACA and take care away from millions of working poor Americans, as many as 5-7 million of whom voted for Trump. The Freedom Caucus were prepared to inflict a 25% cut on Medicaid on the sixteen Republican Governors and legislators who expanded their Medicaid programs and on the rest of the country, heedless of the damage done to Trump’s voters in the rust belt.

Trump did not have an answer to the bloodthirsty nihilists in his own party, a fight he could conceivably have won with a different strategy.

#do your homework, dude. #keep your promises.

Member
Allan
Apr 1, 2017

Thanks for your response to me which is appreciated far more that your op ed. I agree with most of your present points. Additionally I don’t think Trump knows much about healthcare nor does his interest seem to lie in that sphere other than the ACA is an ‘obamination’ (sl) and needs to be changed. I personally disagreed with the Ryan bill and think it was a mistake both economically and strategically.

I can think of some other approaches that I feel would be better. As far as living up to campaign promises and one’s word I look at much of what is said in politics to be puffing. Trump was relatively honest on that scale. His opponent was almost totally dishonest. I don’t think he would have lost had some of his promises regarding healthcare been diminished. He won because the other candidate was terrible.

Too much second guessing that doesn’t leave us any further ahead than before. We are all trying to be mind readers and hypothesize what Trump was thinking. That doesn’t lead us further ahead either for if we are correct it is by accident only. I also saw the bashing of the Tea Party which is more than one group and very diverse. You might not believe that the “the ACA was an assault on liberty”, but I would rather have had you explain what you meant than simply to provide buzz words. After all there has been a question of Constitutionality, debt and large government all of which the ACA contributes to. I’m not trying to take a side here, but these questions are very legitimate and should be a greater part of the discussion than bashing or divining Trump’s motives. I must admit that you covered a lot of territory, probably way too much for one op ed and that I believe diluted some of the points you were trying to make.

Member
Steve2
Apr 1, 2017

“Trump would not have been elected in the first place if he had campaigned on the AHCA.”

Yes. He promised that everyone would get insurance, that it would be cheaper and it would be Great! Then he let Ryan (and probably Price) write the bill.

Steve

Member
Allan
Apr 1, 2017

Steve, as I said politicians make lots of promises. Trump won because Hillary was a lousy candidate and the public was sick and tired of the politicians. Right or wrong some that supported Bernie Sanders voted for Trump as well for the same reason.

As far as I am concerned both parties stink though at the present time the Democrats stink more than the Republicans. Maybe that is because fish gets old fast and the Republicans might have less old fish carcass’s hanging around.

Member
Jwood
Mar 30, 2017

Your hatred for Trump, makes his supporters, like me, enjoy his Presidency so much more. Has no one learned anything by underestimating this guy? He’s been crushing it for the last 50 years. Billionaire in a tough business, through honest wealth, not an internet start up or hedge fund, TV ratings star, great father, loved by his kids, doesn’t drink, doesn’t smoke, President of the United States. But he had a look on his face because the stupid congress couldn’t give him a bill to sign and he’s the idiot, finished, oh no… Trust me, his 60 million plus supporters don’t blame him.

And still, the hatred is like nothing I’ve never seen. Whether on SNL or everywhere else in the media, he will only grow more popular as you call him names, because the 60 million + people who voted for him, love his outsider views. The LANDSLIDE victory he had is still lost on all of you who don’t live in the real world and you don’t understand why he won. Sure… ACA is actually best thing in the world, giving away things to people is easy, making the right decisions and saying no is hard. What would HRC be doing about healthcare right now? Same thing I guess, nothing.

Your use of the ‘alt-right’ term and other playbook terms is so typical. I can’t even debate your topic because your whole premise is based on ACA is actually not that bad… no entitlement is that bad until you look at the math, that does not work and will never work. People LOVE social security, but it’s the same as bernie madeoff ponzi scheme, it’s incredibly under-funded. But no worries the gov’t can solve all problems in the “alt-left” Utopian world. Your also probably against Neil Gorsuch too, right?

Member
Mar 30, 2017

36% favorable, 57% unfavorable. Muslim Ban v1.0, Nyet. Muslim Ban v2.0, Nyet. AHCA-Trump/RyanCare, Nyet.

Member
Jwood
Mar 30, 2017

right around Obama’s numbers… hahahah He’ll be fine. fake polls anyway. Muslim ban, Oh, is that what it was? I thought it was to keep us safe from the same 6 countries that keep killing innocent people, running them over with trucks and what-not… but I’m only watching fake news, so what do I know..?

Member
Allan
Mar 30, 2017

jwood, the left is suicidal and as the true collectivists they are they wish to take everyone else with them.

Member
Mar 30, 2017

Oh, Lordy, we are joined by the Black Knight at the stream crossing in Monty Python’s Holy Grail.

“the left,” “collectivists”… The 1980’s called, they want their cliches back. Comrade “Allan.”

Member
Allan
Mar 31, 2017

After Obama you were left at the stream with your pants down.

Member
Steve2
Apr 1, 2017

“I thought it was to keep us safe from the same 6 countries that keep killing innocent people,”

OMG, we are turning to foreign policy. I have followed the area and topic pretty closely since I served over there. The banned countries have almost no one over here to kill us. They come from the countries not banned, like Saudi Arabia and Pakistan. Also, Obama never had unfavorables or favorables that low.

Steve

Member
Allan
Apr 1, 2017

Congratullations and thank you for your service. The government is trying to vet people coming to our nation. Those countries don’t have reliable governments that can or will help us though I think things changed with Iraq. Trump chose the nations that the Obama administration had listed. He didn’t add the other nations, but maybe if you ask him nicely he will consider doing so.

You like polls. Do you want our government policy to be based upon polls? I don’t care about Trump’s unfavorability rating except in the political necessity sense. I care whether he does good or bad for the country. That is how I looked at Obama and every President. You can follow and cheer your ball team on, right or wrong, but we are dealing with our security, not winning the Superbowl.

Member
pjnelson
Mar 30, 2017

Clearly, as Jeff mentioned, the Trump administration was suddenly dismayed over the change in the AHCA politics at the end. It is possible that this just represented their level of political naivete. It is also possible that within 24 hours, the AHCA support suddenly vanished from politics as usual, and the transition of power to a classical coalition style decision process. I somehow sense that there is likely to be another explanation. Remember that AHCA was designed to reduce the cost of our nation’s healthcare to the Federal government. It did this with several changes, chief of these transferred a large responsibility of Medicaid to the States. It is clear that neither the States involved nor their healthcare institutions would accept that willingly, another unfunded Federally mandated expense. It is certainly possible that the Governors, Legislators and their healthcare institutions suddenly and collectively invested their political capital to end AHCA 2017.
.
If so, what does this say about the future of healthcare reform at the Federal level? And how is it, that the impact of our nation’s cost of healthcare on the stability of our national economy continues to exist only in the proverbial “closet?” The cost of our nation’s healthcare for our economy rests at . @18% of our GDP. Virtually, all of the other developed nation’s are at . 12% . or less of their GDP. I have no reason to believe that anything within our nation’s healthcare reform would be even close to a substantial improvement of its cost. If we really believe this high cost is caused by the adversities inherent in many communities, then we need to screech to a halt and do something realistic about it, community by community.

Member
Mar 30, 2017

So essentially, the ACA was awesome, the public just didn’t know it. If only obama and the dems had sold it better to the ignorant masses. It’s not that many who have an ACA plan aren’t fond of it (I have an ACA plan)…and that the GOP failed to pass a replacement plan because they were divided about how to replace it.

Its a popular assertion to say that the ACA somehow controlled cost. I have made the point repeatedly…it absolutely did not. Year over year spending on health care is higher post ACA not lower. Medicare spending is ‘controlled’ but this was the case in the FFS part of medicare well before the ACA. Overall spending is up. Yes, I know we’re covering x miillion more people…but recall a major selling point of the ACA was to bend the national health care cost curve. THIS DID NOT HAPPEN. As a percentage of total GDP healthcare spend was flat for the years prior to ACA enrollment. This is detailed here in a summary of the CMS 2015 report. http://thehealthcareblog.com/blog/2016/12/26/national-health-expenditures-continue-to-accelerate-in-2015/

Basically, we are presiding over a transfer of a significant portion of the nation’s wealth to insurance companies…with a very narrow band of patients benefiting. I’m glad the commenters and Jeff are so pleased with the result. I guess I just had a much higher bar when I voted for the darn thing.

Member
Member
Jeff Goldsmith
Mar 30, 2017

Game isn’t over.
Remember Coach Taylor in “Friday Night Lights”:
Clear eyes, Full Hearts, Can’t Lose!”

Member
Mar 30, 2017

Yes, nicely done.

What we are seeing right now (Thursday morning, March 30) is Trump declaring war on the Freedom Caucus, and Ryan demanding that they get in line for another vote on his AHCA or he will have to compromise with the Democrats.

These two threats are different because Ryan and Trump are substantially different people. Trump is not very ideological, he just wants to win, to be the winner. And he is a very astute reader of whatever audience he is playing to. That means, in political terms, being a populist, making big promises to “the people” and then producing. So his real goals in healthcare are 1) to “repeal and replace Obamacare” (or at least do something that can be marketed as that, and 2) “take care of everyone.”

Ryan is actually pretty much the opposite. He has an ideology that leads to 1) a smaller government role in everything and 2) lower taxes, especially for the rich. Healthcare reform is just a path to those two main goals for him. He does not believe that government is there to “take care of everyone” at all.

So when Trump declares war on the Freedom Caucus and separately floats the possibility, he is just throwing out bargaining talking points, but he is talking about something he could conceivably go for. When Ryan says, “Get in the van or we’ll have to work with the Democrats,” it’s a total bluff. For him, given the Democrats’ unusual solidarity behind not repealing the ACA or decreasing coverage, working with the Democrats would be complete surrender.

As they thunder down the track for another run at the stone wall they ran into last Friday, Trump’s bluff is not hollow, Ryan’s is.

Member
Millenson
Mar 30, 2017

Nicely done, Jeff. On one small point: Medicare was not “JohnsonCare” because, first of all, both parties had different wings and party-line votes were far, far fewer than today. Secondly, we didn’t have the kind of legislative “branding” we have today; i.e., Affordable Care Act would have been more like the Medicare and CHIP Reconciliation Act. (No one wanted credit and it was bipartisan, so give it a snoozer title.)

Of course, the Civil Rights Act of 1964 didn’t need to be called “Democrats for Post-Reconstruction Democracy” in order for Republicans to use it and similar legislation to create the white-dominated Southern South. However, “blaming” the Great Society for Medicare and Medicaid and other social programs that helped their constituents was never something Southern Republicans were foolish enough to do. At least, until really, really safe districts from state-of-the-art gerrymandering came about.