The Enduring Fantasy of Trump’s Bestest Ever Beautiful GOP Health Care Plan

Donald Trump and the GOP held a majority in both the House and the Senate for the first two years of his presidency.

Despite the fact that Donald campaigned in 2016 on replacing the ACA with something more inclusive — “I am going to take care of everybody … Everybody’s going to be taken care of much better than they’re taken care of now.” — and despite the fact, just before his inauguration, he pinky-swore that he had a detailed Much More Better Great Bestest health care plan to replace the ACA that was just about ready to be printed, voted on, and passed, once he was in office …

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid.

[…] Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.). “It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said.

[…] As he has developed a replacement package, Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion. “We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”

… he then just turned to Congress and basically punted it over to them. Because he had no actual plan. 

The GOP-controlled Congress tried. They spent all of 2017 crafting and recrafting and negotiating within their caucus to get some sort of “repeal and replace” passed. The closest they got was the AHCA, which kicked a bunch of people off of insurance and didn’t cover pre-existing conditions, and which ended up being defeated in a last-second vote by Sen. John McCain in July. Subsequent efforts to just “repeal” and “repeal but delay repeal for two years” also failed.

(Ironically, just as the ACA almost foundered on the gap between folk on the far left of the Dems who wanted a much more sweeping health insurance reform, and the Blue Dog Dems who wanted something much more conservative, the GOP’s efforts were stymied. on conservative Senators and House members who wanted flat-out repeal, and more moderate GOP congressfolk who insisted on a much softer landing.)

The GOP basically gave up in Election Year 2018, but still lost control of the House in that fall’s election, largely over their shenanigans against the ACA, which people suddenly realized they actually kind of liked (or liked more than the status quo ante).

Which brings us to now, when the Trump Administration is seeking to get the ACA defeated in court, while promising that it has (or will have Real Soon Now) the Much More Better Great Bestest health care plan to replace the ACA. It says that, not because it has such a plan (it still doesn’t), but because it expects the GOP in the Senate to write such a plan — something even Mitch McConnell isn’t willing to do.

So instead, Donald has declared he never really wanted it written and voted on before the 2020 election anyway, and will instead actively campaign on how Beautiful and Great his Brand New Plan will be after the election when he inexplicably expects to have control back of the House for the GOP, and so will be able to have something written for him that will be Truly Awesome.

Everybody agrees that ObamaCare doesn’t work. Premiums & deductibles are far too high – Really bad HealthCare! Even the Dems want to replace it, but with Medicare for all, which would cause 180 million Americans to lose their beloved private health insurance. The Republicans…..

— Donald J. Trump (@realDonaldTrump) April 2, 2019

….are developing a really great HealthCare Plan with far lower premiums (cost) & deductibles than ObamaCare. In other words it will be far less expensive & much more usable than ObamaCare. Vote will be taken right after the Election when Republicans hold the Senate & win……

— Donald J. Trump (@realDonaldTrump) April 2, 2019

….back the House. It will be truly great HealthCare that will work for America. Also, Republicans will always support Pre-Existing Conditions. The Republican Party will be known as the Party of Great HealtCare. Meantime, the USA is doing better than ever & is respected again!

— Donald J. Trump (@realDonaldTrump) April 2, 2019

I imagine one can judge the veracity of the full set of tweets by that final line there.

The problem is, no matter how many think tanks and Senators and policy wonks and zany off-hand comments by the President one throws into the picture, what Donald wants, framed in a way that’s acceptable to his own party, is simply impossible.  Mathematically impossible.

Here’s the problem: Insurance companies are completely correct in saying that people with pre-existing conditions tend to need to spend more on medical care, and therefore are more costly to insure.

There’s no getting around that. You can argue over what constitutes a pre-existing condition (unless you’re an insurance company customer before the ACA, because it was then whatever insurance companies wanted to say it was, from having been pregnant to having diabetes to having once smoked to living in the wrong neighborhood to having had acne to having anything that might possibly every remotely be arguably related to something that you now wanted coverage for), but the bottom line is, literally, the bottom line.

If you are going to actually fully cover people regardless of their pre-existing conditions, you have to spend money. Much more money than if you do what insurance companies always want to do (cover only healthy people who won’t ask for the money back that they spent on premiums). Which means either taking that money from the taxpayers (like in a Medicare-for-All scenario), or maximize the risk pool with even fully healthy people so that everyone is mandated to buy insurance and spends marginally more than they would if they were only covering just themselves (if they were lucky enough to not have any “pre-existing conditions”) (which is the approach the ACA took, based on Romneycare, based on what the Heritage Foundation recommended before the Right decided that Obama had stolen the idea and therefore it was the Worst Idea Ever).

The alternative to spending money is to pretend that you are protecting pre-existing conditions. For example, you can require insurance companies to cover everyone, but allow them to charge more for some people — i.e., a person can theoretically get insurance despite their pre-existing conditions, it’s just prohibitively expensive to actually get. Or you can create a special “high risk pool” taxpayer-supported insurance program, and then scrimp on the money you put into it, or distribute it as block grants to the states regardless of inflationary costs or how actual medical care demand is balanced. Those kind of solutions let you claim with a semi-straight face you are protecting people, while in reality throwing them to the dogs.

Of course, you could just go ahead and overtly throw them to the dogs. Some conservative GOP folk think that’s fine — if you can’t pay more, you can go pound sand, I got mine, screw you.

But Trump claims that sort of Randian attitude is unthinkable. But he thinks he will be able to get away with not having to explain the magical details of how he’ll do all these wonderful thing. Like the real estate developer he is, he’ll run on “principles.” just as he tweeted above: Lower costs! Lower Deductibles! Much Better! Everyone covered! We love pre-existing conditions! Puppies and Unicorns for all! We double-dog promise that’s what you’ll get — trust us!

Given the gaps, the people kicked off coverage, the hits to folk who have pre-existing conditions that were coded into the few actual GOP plans proposed over the past couple of years, it’s hard to believe that’s a message that’s going to go over well.

Do you want to know more?

• • No, Mick Mulvaney, Republicans don’t have a respectable record on preexisting conditions – The Washington Post
  • Trump vows ‘insurance for everybody’ in Obamacare replacement plan – The Washington Post (Jan. 2017)
  • 6 promises Trump has made about health care – POLITICO (Mar. 2017)
  • Trump punts on health care until after the 2020 election – CNNPolitics
  • Timeline of ACA repeal and replace efforts – Ballotpedia