Repeal + Replace

Trump’s Obamacare Debacle: Vanquished by a Ghost!

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 https://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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Steve2Ross KoppelAnish KokaHayward ZwerlingSteve Findlay Recent comment authors
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Steve2
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Steve2

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

Allan
Member
Allan

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

Allan
Member
Allan

“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… Read more »

Jeff Goldsmith
Member
Jeff Goldsmith

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… Read more »

Allan
Member
Allan

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… Read more »

Steve2
Member
Steve2

“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

Allan
Member
Allan

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.

Jwood
Member
Jwood

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… Read more »

BobbyGvegas
Member

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

Jwood
Member
Jwood

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..?

Allan
Member
Allan

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

BobbyGvegas
Member

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.”

Allan
Member
Allan

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

Steve2
Member
Steve2

“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

Allan
Member
Allan

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… Read more »

pjnelson
Member
pjnelson

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… Read more »

anish_koka
Editor

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’… Read more »

BobbyGvegas
Member
Jeff Goldsmith
Member
Jeff Goldsmith

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

Joe Flower
Member

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… Read more »

Millenson
Member
Millenson

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… Read more »