The Scorecard: The Great Trump Health Policy Train Wreck

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.


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6 replies »

  1. Our nation’s healthcare reform continues to “circle the wagons” that exist at the core of our nation’s healthcare problems: cost and quality. The annual health spending within our nation’s economy has grown 2.3% annually compounded faster than economy growth for 67 years, unabated other than 1994-1999 ( see Altarum Health spending report 17-04. page 4). And, its uneven quality is most succinctly documented by our nation’s maternal mortality ratio, also unabated since 1960. We are the only advanced/developed nation with a worsening maternal mortality ratio for 25 years ( see UN/WHO/IMF report for 2015). Among the 51 advanced/developed nations, we ranked 41st in 2015.
    As a now recently retired Primary Physician of 41 years, the availability of a very high level healthcare for Complex Health Needs is spectacular. I am sure that many of my colleagues would echo my own view that the fundamental problems have not been identified. Clearly, trying harder and more research will not suffice, with no clear evidence that more time will “clear the air.” As noted by Steven Covey et al in 1994, FIRST THINGS FIRST. ( his best ) At a time when the major vested interests are preoccupied by their own version of “our market share,” there has been no discussion about the number ONE attribute of high quality and lower spending for a advanced/developed nation’s healthcare: equitably available, enhanced Primary Healthcare for each citizen, community by community.
    Second, we must realize that the social determinants of a person level of Unstable HEALTH, cannot be solved by our nation’s healthcare industry. The last available state by state maternal mortality rates (2001-2006) are closely related to the state by state poverty data. There is no reason to believe that 10 years later, it is any different. Do we really believe that the associated low levels of SOCIAL CAPITAL can be solved by a Federal government entitlement process? Clearly, NO. For a clearly defined Safety Net contribution to the COMMON GOOD within a community, clearly YES. We live in times of heroic levels of violence and intense ‘social dilemmas’ that each person encounters daily. Since every community is unique, we will need a community driven and nationally promoted strategy. Remember, the economic ROI for education is 3:1, and for early childhood education, it is a whopping 7:1. The Smith-Lever Act, enacted by Congress in 1914 would be a good starting point. An underlying, well supported and widely acknowledged consensus will be required for the basics of each citizen’s Stable HEALTH. They are Caring Relationships, Collective Action ( see Nobel Prize winner Elinor Ostrom’s Design Principles), COMMON GOOD, Institution ( Elinor Ostrom’s definition is the best), HEALTH (what are the primary determinants of Stable HEALTH) and Social Capital.
    And, finally, we will need a lasting political economic ( not politics ) plan to distribute the economic risk for health spending efficiency among the major decision makers. Most importantly, the evidence for the HMO prominence during the 1990s and their effect on efficient healthcare should not be ignored any longer. Our nation cannot avoid the economic experience of Greece within the last 10 years with our nation’s health spending at 18.2 % of the GDP. It was 5.0% in 1960. ( see Henry Aaron, Ph.D. Commentary, NEJM 2011). At the least, our Nation must continue to honor our tradition of State’s rights for this resolution.
    see http://www.nationalhealthusa.net/home/rationale/

  2. That is true, but as competitiveness heats up worldwide we have to be better and better. Unnecessary healthcare costs should not defeat our ability to compete.

  3. Thanks for kind words!

    You can say that his promise to ring fence Medicare and Medicaid was “hollow” but given the median Trump voter was 57 yrs old, and the narrowness of his victory margin in the three swing states, it probably was responsible for his being President. Had he hewed to the “eat your spinach” fiscal conservative traditional Republican line about “entitlements”, he’d be back opening hotels and golf courses.

    Though no one wanted to make the argument publicly, the rationale for reallocating $$ from health spending to tax cuts was that health spending was “not productive” use of social capital. By returning $$ to investors, dogma says jobs get created. The reality: the layoffs in hospitals, etc. would more than cancel out the new jobs.

  4. This is an outstanding review

    I would add that the Trump’s campaign commitment on health insurance, ie, “better and cheaper” and “for everyone” was hollow as a gourd from day one and set the stage for this mega-failure.

    No surprise that conjuring a plan to follow-up that impossible promise satisfied none of the stakeholders. It left too much of the ACA intact for the libertarian Republican right and would have increased the ranks of the insured too much for Democrats and Republican moderates. The upper class tax cuts thinly masqueraded as healthcare reform. Lastly, they tried to cover up the anticipated effects first by ignoring them and then by denying the CBO estimates that everyone knew were common sense extrapolations from the reduced funding. Finally, tried to do all this and alter the nation’s entire healthcare landscape without hearings or public discussion.

  5. Love him, or hate him, that’s it. Seems there is no middle ground for our president. Biggest promise broken so far: WILL HAVE THE SMARTEST AND BEST PEOPLE IN THE WHITE HOUSE! He needs to get real, fire “chief strategist” and put an ad in the paper for some good people, and pay them out of pocket to get some real talent in there. Stop the clown show, would be my humble proposal.