How Trump Could Still Win the Health Care Fight
Policy + Politics

How Trump Could Still Win the Health Care Fight

Jonathan Ernst

Democrats may be dancing on the grave of the Republican effort to repeal and replace the Affordable Care Act, but there’s a real danger that like the suckers in a horror movie celebrating the monster’s death a bit too soon they could be in for an unpleasant surprise.

But if President Trump manages to raise ACA repeal from the grave, he’ll be doing it in spite of himself.

Related: Surprise! There Are Now Two Senate GOP Health Care Bills in Play

The Senate’s failure last week to pass one of three different alternatives to the ACA that came up for votes was, no doubt, a major embarrassment to both President Trump and Majority Leader Mitch McConnell. And, as he does when frustrated or embarrassed, Trump took to Twitter in a rage that extended into the weekend.

Republicans in the Senate looked like “fools” he wrote. The institution of the Senate itself has become a “JOKE.”

On Saturday, still on Twitter, Trump crossed the line into public threats. He said that unless he is presented with legislation “quickly” that he would cut off what he called “BAILOUTS” of both the insurance industry and of lawmakers themselves. The twin threat was broadly viewed as a promise to do two things.

First, Trump seemed to be suggesting that he would cut off the cost-sharing payments to insurance companies that were created under the ACA. The payments compensate insurers for offering cheaper premiums to low-income Americans. Health insurance experts warn that cutting off the payments could cause the individual health insurance market to crash.

Related: The Health Care Fight Isn't Over, Despite Democratic Cheering

Second, Trump is apparently threatening the federal healthcare subsidy for lawmakers and their Capitol Hill staff. Prior to the ACA’s passage members of Congress and their staff, like most Americans, got their health insurance through their employer -- in this case, the federal government.

However, Republicans pushed for and passed a measure requiring lawmakers and their staff to buy their insurance from a health insurance exchange created under the ACA. After some wheeling and dealing, the Obama administration drafted a rule allowing lawmakers and staff to receive premium subsidies that covered a similar percentage of their health care expenses as the federal government had prior to the law’s passage. On Saturday, Trump appeared to be threatening to cut that off.

And just in case he hadn’t already alienated everyone on Capitol Hill, he renewed his call for the Senate GOP majority -- mentioning McConnell by name -- to do away with the legislative filibuster. There may be things that members of Congress hate more than a president telling them how to run the co-equal branch of government that they control. But not many.

But the good news for Trump is that there is yet another measure to do away with the ACA making its way through the Senate, and it might be able to gain the support necessary to pass.

Related: ‘Skinny Repeal’ Takes Center Stage, but May Find Little Love in Senate

So far, most of the efforts to undo Obamacare have fallen into one of two categories, either a straight repeal of all or most of the law with a promise to replace it later, or what amounts to a watering down of the law by tinkering with mandates, taxes, and insurance regulations.

However, South Carolina Sen. Lindsey Graham and Louisiana Sen. Bill Cassidy have been pushing a very different alternative that has several elements going for it that weren’t present in earlier proposals.

Announcing the plan in mid-July, Graham said, “In a nutshell, we’re keeping the [ACA] taxes in place on the wealthy, we’re repealing the individual mandate and the employer mandate, and the medical device tax that 75 senators voted to repeal. There’s about $500 billion in money, rather than trying to run health care from Washington, we’re going to block grant it to the states, and here’s what will happen.

If you like Obamacare, you can re-impose the mandates at the state level. You can repair Obamacare if you think it needs to be repaired. You can replace it if you think it needs to be replaced. It will be up to the governors. They’ve got a better handle on this than any bureaucrat in Washington.”

That’s about as much in the way of details that most people have seen of the Graham-Cassidy plan. But on its face, it has at least two major upsides for Republicans.

Related: What a Waste—Senate Health Care Debate Squanders Time and Millions for Nothing

In the run up to last week’s votes, Congressional Budget Office scores of various ACA replacement plans had been the Republicans’ bane. Every time they produced a plan, the CBO would declare that it would save billions of dollars, but that it would also inevitably cause millions of Americans to lose their health insurance.

In terms of cost, the Graham-Cassidy plan would be relatively simple to score. The beauty of block grants is that they are nothing if not predictable. And if all it is doing is taking existing tax revenue and redirecting it to block grants, it’s not likely to have much impact on the budget. But it would be exceedingly difficult for CBO to estimate the impact on health insurance coverage. Because every state would be in charge of implementing its own health insurance system, which could run the gamut from keeping the ACA in place, to starting from scratch, and everything in between, an estimate with any degree of reliability would be virtually impossible.

Second, the proposal lifts the burden of responsibility from members of Congress. One of the biggest objections that Republican lawmakers had to the measures presented last week was that they created systems that, arguably, would hurt millions of Americans. The Graham-Cassidy bill creates no system at all, but rather passes the buck to the states.

This is not to suggest that the bill would face a smooth path to passage. The idea of retaining taxes imposed under the ACA would be a bitter pill for many Republicans, particularly members of the House Freedom Caucus. But Freedom Caucus Chairman Mark Meadows of North Carolina has been meeting with Graham and his supporters in order to try to find common ground, Politico reported Saturday.

And considering that the GOP is in full charge of the federal government, and is facing a logjam of must-pass legislation this fall, including a debt-ceiling increase and a new federal budget, passing something and declaring victory over the ACA is going to look increasingly appealing as the summer drags on.