For the second time in just four months, President Trump finds himself standing on the sidewalk reeling and looking for the license number of the health policy truck that hit him.
In the wake of Senator John McCain’s unexpected vote last week killing the “skinny” version of ACA repeal, Republicans abandoned their efforts to “repeal and replace” ObamaCare.
Though the process may not be “over” as of this writing, this has been the most catastrophically mismanaged federal health policy cycle we’ve seen in our lifetimes. In this post, I turn to Blumenthal and Morone’s 2009 analysis, The Heart of Power: Health and Politics in the Oval Office” for help in deconstructing the Trump Presidency’s politically costly health policy adventure.
Blumenthal and Morone distilled eight key lessons about how to manage the health care issue from the records of the post-Roosevelt Presidents’ health policy efforts. Attached to each lesson is a letter grade for Trump’s performance.
To succeed in health reform, President must “care deeply” about the issue.
Candidate Trump did not pretend to be a health policy expert, but the most potent applause line in his campaign speeches was his promise to the Republican base to “repeal and replace” ObamaCare. Trump complicated his task, perhaps without fully realizing it, by running way to the left of his base in promising not to cut Medicare and Medicaid and to give people better coverage for less money.
The challenge of rearranging federal involvement in healthcare financing within the “repeal and replace” promise was clearly a good deal more complex than candidate Trump expected, and he candidly admitted as much. One can criticize the Clintons for many aspects of their 1993-94 failed health reform effort, but their substantive grasp of the policy choices involved was truly impressive. Either Clinton could have commanded the stage in a graduate seminar on health policy at Harvard or Hopkins.
Trump, not so much. His repeated references to “the healthcare” as his shorthand on the issue were not an encouraging sign of his immersion in the issue, but the following verbatim excerpt from his July 19, 2017 interview with the New York Times was a masterpiece:
“So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, ‘I want my insurance.’ It’s a very tough deal, but it is something that we’re doing a good job of.”
This was despite multiple earnest efforts by numerous outside parties -Zeke Emanuel (in person) and Avik Roy, James Capretta, Joe Antos and Gail Wilensky (in editorial venues ) to educate him on the knotty substantive problem with repealing ObamaCare’s coverage guarantees, and a host of other issues. At its root, the TrumpCare debacle can be laid at the feet of Presidential disengagement. Trump’s grade: F.
The need for speed. Blumenthal and Morone wrote; “The day after the presidential election, the savvy health policy analyst will slip his or her president-elect a message: ‘Hurry up- you’re running out of time.’ The window of opportunity always slams shut quickly.” In former Senator Alan Simpson’s immortal words: “Healthcare is like bear meat. The longer you chew it, the bigger it gets.” Presidents do not always control their agendas (see Obama/World Financial Crisis), but early is good., as public passion for the issue cools with each passing month as complexities and industry reaction grow.
The practical reality: the closer one gets to mid-term elections, the less willing vulnerable Congress people are to risk political capital on healthcare legislation that may not help them. Despite the commitment to “repeal and replace” on Day 1, the lengthening delay in dealing with the rest of the Trump agenda (tax reform, infrastructure) plus budget and debt ceiling weighs heavily. Trump’s Grade on Speed: D, so far.
Bring a Plan with You. Blumenthal and Morone stressed the importance of “coming into office with a legislative proposal in hand”. In Trump’s case, this was deceptive, because actual legislation was passed by previous Republican Congresses to “repeal and replace” ObamaCare, albeit with full confidence of a Presidential veto. But in the real world of 2017, the political and health system consequences of repeal were untested. The prior legislation was, in other words, completely and blissfully reactionary: symbolically repealing the “Obama” part of ObamaCare, without contending with the messy realities of 20 + million dispossessed individuals, or the stability of the partially federalized individual insurance market. The bill the House passed in May could easily have been titled The Political Revenge and Upward Redistribution Act of 2017, mainly a huge tax cut for corporations and high income individuals, which bore no relation whatsoever to Trump’s campaign promises. Thus, Trump rates an exculpatory C on Bring a Plan, but an F for situational awareness and an F- for fidelity to his campaign platform.
Hush the Economists. Blumenthal and Morone believed that “expanding health coverage requires presidents who are able and willing to overrule their economic advisors”. This is presumably because at any given moment in any health reform debate, someone in the administration will ask “can we afford to expand coverage?”, and deficit hawk economists will answer “not now.”
Here, I disagree with the substance of Blumenthal and Morone’s analysis: health policy cannot exist in a fiscal vacuum; financing must be sustainable for the coverage expansion to last. Part of ObamaCare’s problem was that the unrealistic White House policy requirements that ObamaCare reduce the deficit and that capped the cost at under $1 trillion-both imposed by the President’s political advisors. These economic constraints resulted in inadequate subsidies, mediocre actual dollar coverage and tepid public reaction to the reforms.
However, the Trump process was not driven by policy, economic or otherwise. It was completely political. Since economists played zero role in the TrumpCare debacle, Trump gets an A for ignoring their input.
Go Public. “There is only one job the president can do: create popular momentum for reform”. Here, Trump’s disengagement played a crucial role. Public support for ObamaCare was always lukewarm, rising above 50% exactly one month and languishing in the 40’s in the Kaiser tracking polls for most of the ensuing seven years. Yet, with a vulnerable target, , Trump continuing to pound on the one note “ObamaCare is a disaster” as evidence mounted of the potential harm done to specific individuals, including Trump’s own electoral base from repealing it. His surrogates didn’t help much, either. Sec. Tom Price was caught claiming that the House bill would not result in Medicaid patients losing coverage, despite multiple Congressional Budget Office findings of eight-figure enrollment declines. The result was a steady increase in the popularity of the law. Trump gets a D- on Going Public.
Manage Congress. “The successful president must be nimble at making our convoluted legislative machinery work.” Trump’s job here was made difficult not only by his campaign promises discussed above, but also by profound divisions in his own party. There were at least three distinct Congressional factions (and therefore agendas): the hardcore Freedom Caucus folks (“Repeal” is fine. Screw “Replace”), the Deficit Hawks (Must Shrink Federal Fiscal commitment to Medicaid AND Medicare, not just roll back the coverage expansion) and the Repeal and Replace (but Leave Medicaid Expansion alone)- the twenty Republican Senators whose states expanded coverage. Similar intraparty divisions cratered the Clinton reforms and nearly killed ObamaCare.
Even a skilled legislative tactician would have struggled to craft a working Senate majority from this divided Republican troop configuration, with only two votes to lose. In retrospect, McConnell came remarkably close, but Trump made his job much harder with huge relationship damage from gratuitous public bullying of Mark Meadows, Lisa Murkowski, Dean Heller, and others. Trump oscillated between complete disengagement and unhelpful and ill-timed interventions. Between clumsy public cajoling, private threats, and constant Twitter driven tactical second guessing, Trump earns an F for capricious and inconstant management of Congress.
Forget the PSROs. This was Blumenthal and Morone’s injunction to Presidents not toget caught up in health policy minutiae. Per #1 above, not a problem for Trump. Grade: A.
Learn How to Lose. Blumenthal and Morone’s message: Given the historical record of the past eighty plus years, the odds are that a given President will be unsuccessful in accomplishing major health reforms. By “learning how to lose”, they meant disengaging gracefully, leaving the door open not only to dissident members of his own party, but collaboration with the other political party to enable incremental progress in the rest of the Presidential term. The Clintons did this, and achieved significant administrative progress with HIPAA in 1996, and a significant coverage expansion with S-CHIP in 1998, both bipartisan bills.
So far, Trump seems not to grasp the “disengage with grace” logic. His recent tweets on the subject show a pronounced disinclination to move on. They have been angry, petulant and insulting (“fools”, “total quitters”, threatening their health coverage) not only to his shaken majorities but to the Democrats who might be future partners in insurance market reforms. Jimmy Carter once said, “Show me a good loser and I’ll show you a loser”, but this is a pretty impressive case of sore loser-ism. Grade so far, F.
As Blumenthal and Morone made abundantly clear in their book, health reform is a devilishly difficult policy and political challenge for any President, even for those who prepared for it years in advance. Lacking a White House health policy presence, and strong White House issue and legislative management, Trump managed to squander a boatload of political capital on his thusfar unsuccessful ObamaCare initiative. Perhaps with a new White House chief of staff, and candid conversation with his Congressional Republican leadership, the President can minimize the negative impact of the TrumpCare debacle on the rest of his domestic policy agenda.