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.