It took the Obama administration and congressional Democrats nearly two years to design and enact the 2010 Affordable Care Act, the revolutionary and highly controversial program that provides subsidized health insurance to 20 million previously uninsured Americans.
That followed decades of debate and infighting by Democratic and Republican lawmakers, public policy experts and the hospital and insurance industries on the most effective and financially feasible way to go. The fight over Obamacare became so inflammatory that not a single Republican in the House or Senate voted for it on final passage, fearing to invoke the wrath of the Tea Party.
So it’s not surprising that in the wake of Republican billionaire Donald Trump’s s historic victory over Democrat Hillary Clinton for president last week, Trump and Republican leaders who have long called for the repeal and replacement of Obamacare are now struggling to concoct a workable alternative that won’t abruptly strip millions of low and middle-income people of their health care insurance and trigger a revolt.
Trump has begun to drop hints in interviews as to what “Trumpcare” might look like once he and Congress repeal the heart of President Obama’s signature health care program. But for now it is very much a work in progress – and one with an uncertain timetable.
During the campaign, Trump repeatedly vowed repeal Obamacare on the first day of his presidency in January. Republican leaders including House Speaker Paul Ryan (R-WI) and House Budget Committee Chair Tom Price (R-GA) laid the groundwork for such action with legislation that could be rammed through the Senate with a simple majority under obscure budgetary rules and a 37-page blueprint of a replacement that reflects the Republicans’ preference for market-based solutions and reforms of Medicaid and Medicare.
Yet in an interview Friday with The Wall Street Journal, Trump appeared to soften his stand on Obamacare just as he appears to be downplaying some of his other highly controversial campaign pledges, such as barring all Muslims from the country and building a wall along the southern border.
Trump complained that Obamacare had become so unworkable and expensive that “you can’t use it.” He and other Republicans have cited a 22-percent increase in the average cost of premiums for the coming year and a surge in the number of insurers bailing out of the program as evidence. However, rather than promising instantaneous results, Trump told The Journal, “Either Obamacare will be amended or repealed and replaced.”
As he did a number of times during the campaign, Trump said he would consider preserving some elements of the Affordable Care Act, including a rule preventing private insurers from denying people coverage because of pre-existing medical problems and another that allows parents to keep their children on their policies until their children turn 26.
“I like those very much,” the president-elect said in the interview.
Trump said that his sudden change in tone on health care may have been influenced by his post-election meeting with Obama at the White House on Thursday when the president defended his health insurance program and suggested areas of Obamacare that should be preserved.
“I told him I will look at his suggestions, and out of respect, I will do that,” Trump said during the interview at his office in Trump Tower.
Beyond his comments to The Journal and similar remarks in another interview with CBS’s 60 Minutes that will be aired in full on Sunday evening, new plans that have begun to appear on Trump’s transition website differ from some of his heated campaign rhetoric and are more closely aligned with the mainstream Republican agenda.
For example, the revised health care proposals eliminate any mention of attempting to contain high drug prices by allowing the importation of cheaper brands – an apparent sop to the U.S. pharmaceutical industry that strongly opposes that measure. And the website includes new language regarding modernizing Medicare, “a potential nod to congressional efforts to give people vouchers toward buying private health insurance,” according to The New York Times.
Trump’s election caught many by surprise and caused enormous consternation among health care consumer advocacy groups, medical providers, hospitals and insurers, all of whom have a huge economic stake in the perpetuation of a national health care program that has drawn millions of previously uninsured Americans into the market.
Many of the most controversial provisions of the Affordable Care Act that Trump and the GOP now want to repeal were all carefully negotiated to meet the conflicting demands of special interests – including mandating uninsured Americans to purchase coverage, requiring employers to provide coverage for their workers, and determining the level of federal tax subsidies for lower-income families to acquire affordable health insurance.
One of the biggest tradeoffs involved the administration’s demand for a prohibition against insurance companies discriminating against applicants with chronic health problems or older people with costlier medical needs. The insurers, in the end, went along with that, but only in return for the individual mandate that would force healthier, younger people into the market and lower the insurers’ overall costs of coverage.
If the Republicans and Trump succeed in tampering with or repealing these and other elements of the legislation, Obamacare will collapse of its own weight. Consumers denied federal subsidies will stop buying insurance on the government-run exchanges. Major health insurers that already have lost millions of dollars by miscalculating or low-balling the premiums they should charge will sharply scale back or end their coverage in many parts of the country. And hospitals and other health providers that have counted on a major increase in insured patients would suffer huge financial losses.
There is also the question of what will become of the millions of low-income adults who have received health care coverage for the first time under the expanded Medicaid program in 31 states and the District of Columbia – with the federal government picking up 90 percent of the cost under Obamacare.
The notion of abruptly repealing the existing program and implementing a replacement in a seamless fashion without sending the insurance and hospital industries into a panic and rescinding coverage for more than 20 million Americans seems far-fetched at best.
Even if the Republicans give themselves a two-year transition period in which to develop a workable alternative before completely pulling the plug on Obamacare, the experience of the Democrats in negotiating the existing program is an important lesson in the daunting challenges facing Trump.
Still, the president-elect who has spent a career in real estate development and never served a day in public office betrayed little doubt that he could orchestrate such a sea change in federal health care policy and operations without creating widespread hardship for Americans – and a likely political backlash in the 2018 mid-term elections.
“We’re going to do it simultaneously – it’ll be just fine,” he said during his interview with 60 Minutes.